Matt’s Act

To limit the price of insulin drugs accessible for participants, beneficiaries, and enrollees enrolled in group or individual health insurance coverage and group health plans and for uninsured individuals who have diabetes, and for other purposes. 1. Short title This Act may be cited as the Matt’s Act 2. Insulin net price protection (a) Publishing of net price by manufacturers (1) In general A manufacturer of an insulin drug shall, on a quarterly basis, publish on the internet website of such manufacturer the average net price of each such insulin drug for the preceding calendar quarter. (2) Enforcement In the case that a manufacturer of an insulin drug fails to comply with paragraph (1), a Federal agency or program may not make payment for such insulin drug of such until such manufacturer complies with such paragraph. (b) Net price for insulin drugs for certain individuals (1) Application to PHSA plans Subpart 1 of part A of the Public Health Service Act ( 42 U.S.C. 300gg et seq. 2730. Net price for insulin drugs (a) Availability of net price With respect to plan years beginning on and after January 1, 2022, a health insurance issuer offering group or individual health insurance coverage shall provide a participant, beneficiary, or enrollee who has diabetes access to an insulin drug at— (1) the lesser of— (A) the 10 percent of the average net price for such drug published pursuant to section 2(a) of Matt’s Act, plus the average charges for distribution and dispensing described in subsection (c) for such drug; (B) the coinsurance amount for an insulin drug under the health insurance coverage under which such an individual is a participant, beneficiary, or enrollee would otherwise be responsible notwithstanding this section; or (C) $20; or (2) $0, in the case such a participant, beneficiary, or enrollee is enrolled in a high deductible health plan (as defined in section 223(c)(2) (b) Waiver of deductible In applying subsection (a), such a participant, beneficiary, or enrollee shall have access to an insulin drug without regard to a deductible. (c) Charges for distributing and dispensing (1) In general For purposes of subsection (a), charges for distribution and dispensing described in this subsection— (A) are charges associated with the transactions, with respect to an insulin drug, between wholesalers, distributors, retailers, and pharmacies; and (B) may not exceed 10 percent of the average net price of such an insulin drug. (2) Reporting requirement for plans In the case that a health insurance issuer offering group or individual health insurance coverage charges a participant, beneficiary, or enrollee for average charges for distribution and dispensing pursuant to subsection (a)(1), the health insurance issuer shall submit to the Inspector General of the Department of Health and Human Services information with respect to such charges and the amount of the charges. (3) Report to Congress by Inspector General Beginning January 1, 2023, and annually thereafter, the Inspector General shall review the charges described in paragraph (2) and submit to Congress a report on such on review. (d) Definitions In this section: (1) Insulin (A) In general The term insulin (B) Exclusion Such term does not include any medical supplies that provides for the monitoring of insulin levels. (2) List price The term list price (3) Net price The term net price (4) Prescription drug The term prescription drug . (2) Application to ERISA plans Subpart A of part 7 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185 et seq. 704. Net price for insulin drugs (a) Availability of net price With respect to plan years beginning on and after January 1, 2022, a group health plan shall provide a participant, beneficiary, or enrollee who has diabetes access to an insulin drug at— (1) the lesser of— (A) the 10 percent of the average net price for such drug published pursuant to section 2(a) of Matt’s Act, plus the average charges for distribution and dispensing described in subsection (c) for such drug; (B) the coinsurance amount for an insulin drug under the group health plan which such an individual is a participant, beneficiary, or enrollee would otherwise be responsible notwithstanding this section; or (C) $20; or (2) $0, in the case such a participant, beneficiary, or enrollee is enrolled in a high deductible health plan (as defined in section 223(c)(2) (b) Waiver of deductible In applying subsection (a), such a participant, beneficiary, or enrollee shall have access to an insulin drug without regard to a deductible. (c) Charges for distributing and dispensing (1) In general For purposes of subsection (a), charges for distribution and dispensing described in this subsection— (A) are charges associated with the transactions, with respect to an insulin drug, between wholesalers, distributors, retailers, and pharmacies; and (B) may not exceed 10 percent of the average net price of such an insulin drug. (2) Reporting requirement for plans In the case that a group health plan charges a participant, beneficiary, or enrollee for average charges for distribution and dispensing pursuant to subsection (a)(1), the group health plan shall submit to the Inspector General of the Department of Health and Human Services information with respect to such charges and the amount of the charges. (3) Report to Congress by Inspector General Beginning January 1, 2023, and annually thereafter, the Inspector General shall review the charges described in paragraph (2) and submit to Congress a report on such on review. (d) Definitions In this section: (1) Insulin (A) In general The term insulin (B) Exclusion Such term does not include any medical supplies that provides for the monitoring of insulin levels. (2) List price The term list price (3) Net price The term net price (4) Prescription drug The term prescription drug . (3) Uninsured individuals (A) In general Beginning on and after January 1, 2022, a pharmacy shall provide to any individual who has diabetes and is not enrolled in any health plan access to an insulin drug at the average net price for such drug published pursuant to subsection (a), plus the average charges for the distribution and dispensing described in subparagraph (C) for such drug. (B) Review of charges Beginning January 1, 2023, and annually thereafter, the Inspector General of the Department of Health and Human Services shall review the amount of charges paid by an individual described in subparagraph (A) and submit to Congress a report on such review. (C) Charges for distributing and dispensing For purposes of subparagraph (A), charges for distribution and dispensing described in this subsection— (i) are charges associated with the transactions, with respect to an insulin drug, between wholesalers, distributors, retailers, and pharmacies; and (ii) may not exceed 10 percent of the average net price of such an insulin drug. (D) Definitions In this section: (i) Insulin (I) In general The term insulin (II) Exclusion Such term does not include any medical supplies that provides for the monitoring of insulin levels. (ii) List price The term list price (iii) Net price The term net price (iv) Prescription drug The term prescription drug 21 U.S.C. 321(g) 21 U.S.C. 353(b)(1)

Summary: Matt's Act This bill limits the amount that private health insurance plans may charge plan holders for insulin drugs to a maximum of $20, or $0 for high deductible plans; pharmacies may charge uninsured individuals the average price of such drugs after deducting any rebates and discounts provided by drug manufacturers, plus limited additional charges for distributing and dispensing costs.