Pharmacy Benefit Manager Sunshine and Accountability Act

To amend title XI of the Social Security Act to strengthen transparency requirements with respect to pharmacy benefit managers. 1. Short title This Act may be cited as the Pharmacy Benefit Manager Sunshine and Accountability Act 2. Strengthening pharmacy benefit manager transparency requirements Section 1150A of the Social Security Act ( 42 U.S.C. 1320b–23 (1) in subsection (a)— (A) in paragraph (1), by striking ; or (B) in paragraph (2), by striking the comma at the end and inserting ; or (C) by adding at the end the following new paragraph: (3) a group health plan or health insurance issuer offering group or individual health insurance coverage (as such terms are defined in section 2791 of the Public Health Service Act), ; (2) by amending subsection (b) to read as follows: (b) Information described The information described in this subsection is the following with respect to services provided by a health benefits plan or PBM for a contract year: (1) With respect to a contract with each entity described in paragraphs (1) through (3) of subsection (a), the aggregate dollar amount of all— (A) rebates that a PBM or health benefits plan received under each such contract from all drug manufacturers; (B) administrative fees that a PBM or health benefits plan received under each such contract with from all drug manufacturers; (C) administrative fees that a PBM or health benefits plan received under each contract from each such entity; (D) rebates that a PBM or health benefits plan received under each contract with each entity from all pharmaceutical manufacturers that were not passed through to such entities; (E) administrative fees that a PBM or health benefits plan received under each contract from all pharmaceutical manufacturers and did not pass through to such entities; (F) total post-claim adjudication payments that a PBM or health benefits plan collected from a pharmacy under each contract, including any fees, reimbursements, or other claw backs including generic effective rate and brand effective rate contracts; and (G) any post-claim adjudication payments that a PBM or health benefits plan collected from a pharmacy under each contract, including any fees, reimbursements, or other claw backs including generic effective rate and brand effective rate contracts that were not passed through to such entities. (2) The aggregate retained rebate percentage under each contract (that is the value in paragraph (1)(D) divided by the value in paragraph (1)(A)). (3) Across all contractual relationships for each PBM whereby such PBM is managing prescription drug coverage for a entity described in in paragraphs (1) through (3) of subsection (a), the highest retained rebate percentage and lowest retained rebate percentage for each contract under which such PBM provided services. ; (3) in subsection (c)— (A) in the matter preceding paragraph (1), by striking , plan, or prices charged for drugs, or plan, the prices charged for a specific drug or classes of drugs, or the amount of any rebates provided for a specific drug or classes of drugs, (B) by adding at the end the following new paragraph: (5) To carry out the reporting requirement under subsection (e). ; and (4) by adding at the end the following new subsections: (e) Public reporting requirement Not later than the first calendar quarter following the first full plan year beginning on or after the date of enactment of this subsection, and annually thereafter, the Secretary shall publish on a public website of the Department of Health and Human Services the information reported under subsection (b), in accordance with the confidentiality requirements described in subsection (c). (f) Definitions In this section: (1) Brand effective rate The term brand effective rate (2) Generic effective rate The term generic effective rate (3) Pharmacy benefits manager The term pharmacy benefits manager PBM (A) an entity that manages prescription drug benefits on behalf of an entity described in paragraphs (1) through (3) of subsection (a); and (B) for purposes of this section, includes any other organization that— (i) has directly or indirectly (as determined by the Secretary in regulations), an ownership interest of 5 percent or more in the PBM; (ii) shares, or is otherwise a part of, the same organizational structure as the PBM; (iii) exercises operational, financial, or managerial control over the PBM or a part thereof, or provides policies or procedures for any of the operations of the PBM, or provides financial or cash management services to the PBM; or (iv) provides management or administrative services, management or clinical consulting services, or accounting or financial services to the PBM. (4) Organizational structure The term organizational structure (A) a corporation, the officers, directors, and shareholders of the corporation who have an ownership interest in the corporation which is equal to or exceeds 5 percent; (B) a limited liability company, the members and managers of the limited liability company; (C) a general partnership, the partners of the general partnership; (D) a limited partnership, the general partners and any limited partners of the limited partnership who have an ownership interest in the limited partnership which is equal to or exceeds 5 percent; (E) a trust, the trustees of the trust; or (F) any other person or entity as the Secretary determines appropriate. .

Summary: Pharmacy Benefit Manager Sunshine and Accountability Act This bill expands and otherwise modifies reporting requirements for pharmacy benefit managers (PBMs). Current law requires PBMs that contract with plans under the Medicare prescription drug benefit or plans that are offered on state health insurance exchanges to report certain information regarding rebates, fees, and other related information. The bill applies these requirements to PBMs that contract with private health insurers, and it expands these requirements to include more specific information relating to prices and fees, such as rebates that the PBM receives from drug manufacturers that are not passed through to other entities and the highest and lowest rebate percentages the PBM receives among all its contracts. The bill also requires the Department of Health and Human Services to annually post the information reported by PBMs on its website.