efits management services on behalf of a group 
health plan shall submit to the Comptroller General 
of the United States each of the first 4 reports sub-
mitted to a plan sponsor under paragraph (1) with 
respect to such coverage or plan, and other such re-
ports as requested, in accordance with the privacy 
requirements under paragraph (2), the disclosure 
and redisclosure standards under paragraph (3), the 
standards specified pursuant to paragraph (5), and 
such other information that the Comptroller General 
determines necessary to carry out the study under 
section 103(d) of the Health Care Price Trans-
parency Act of 2023. 
‘‘(5) STANDARD FORMAT.—Not later than 18 
months after the date of enactment of this section, 
the Secretary shall specify through rulemaking 
standards for health insurance issuers and entities 
required to submit reports under paragraph (4) to 
submit such reports in a standard format. 
‘‘(c) ENFORCEMENT.— 
‘‘(1) IN
GENERAL.—Notwithstanding section 
2723, the Secretary, in consultation with the Sec-
retary of Labor and the Secretary of the Treasury, 
shall enforce this section. 
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‘‘(2) FAILURE TO PROVIDE TIMELY INFORMA-
TION.—A health insurance issuer or an entity pro-
viding pharmacy benefits management services that 
violates subsection (a) or fails to provide information 
required under subsection (b) shall be subject to a 
civil monetary penalty in the amount of $10,000 for 
each day during which such violation continues or 
such information is not disclosed or reported. 
‘‘(3) FALSE INFORMATION.—A health insurance 
issuer or entity providing pharmacy benefits man-
agement services that knowingly provides false infor-
mation under this section shall be subject to a civil 
money penalty in an amount not to exceed $100,000 
for each item of false information. Such civil money 
penalty shall be in addition to other penalties as 
may be prescribed by law. 
‘‘(4) PROCEDURE.—The provisions of section 
1128A of the Social Security Act, other than sub-
section (a) and (b) and the first sentence of sub-
section (c)(1) of such section shall apply to civil 
monetary penalties under this subsection in the 
same manner as such provisions apply to a penalty 
or proceeding under section 1128A of the Social Se-
curity Act. 
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‘‘(5) WAIVERS.—The Secretary may waive pen-
alties under paragraph (2), or extend the period of 
time for compliance with a requirement of this sec-
tion, for an entity in violation of this section that 
has made a good-faith effort to comply with this sec-
tion. 
‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to permit a health insurance issuer, 
group health plan, or other entity to restrict disclosure to, 
or otherwise limit the access of, the Secretary of Health 
and Human Services to a report described in subsection 
(b)(1) or information related to compliance with sub-
section (a) or (b) by such issuer, plan, or other entity sub-
ject to such subsections. 
‘‘(e) DEFINITION.—In this section, the term ‘whole-
sale acquisition cost’ has the meaning given such term in 
section 1847A(c)(6)(B) of the Social Security Act.’’; and 
(2) in section 2723 of such Act (42 U.S.C. 
300gg–22)— 
(A) in subsection (a)— 
(i) in paragraph (1), by inserting 
‘‘(other than subsections (a) and (b) of 
section 2799A–11)’’ after ‘‘part D’’; and 
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(ii) in paragraph (2), by inserting 
‘‘(other than subsections (a) and (b) of 
section 2799A–11)’’ after ‘‘part D’’; and 
(B) in subsection (b)— 
(i) in paragraph (1), by inserting 
‘‘(other than subsections (a) and (b) of 
section 2799A–11)’’ after ‘‘part D’’; 
(ii) in paragraph (2)(A), by inserting 
‘‘(other than subsections (a) and (b) of 
section 2799A–11)’’ after ‘‘part D’’; and 
(iii) in paragraph (2)(C)(ii), by insert-
ing ‘‘(other than subsections (a) and (b) of 
section 2799A–11)’’ after ‘‘part D’’. 
(c) ERISA.— 
(1) IN GENERAL.—Subtitle B of title I of the 
Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1021 et seq.) is amended— 
(A) in subpart B of part 7 (29 U.S.C. 
1185 et seq.), by adding at the end the fol-
lowing: 
‘‘SEC. 726. OVERSIGHT OF PHARMACY BENEFITS MANAGER 
SERVICES. 
‘‘(a) IN GENERAL.—For plan years beginning on or 
after the date that is 3 years after the date of enactment 
of this section, a group health plan or health insurance 
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issuer offering group health insurance coverage, or an en-
tity or subsidiary providing pharmacy benefits manage-
ment services on behalf of such a plan or issuer, shall not 
enter into a contract with a drug manufacturer, dis-
tributor, wholesaler, subcontractor, rebate aggregator, or 
any associated third party that limits the disclosure of in-
formation to plan sponsors in such a manner that prevents 
the plan or issuer, or an entity or subsidiary providing 
pharmacy benefits management services on behalf of a 
plan or issuer, from making the report described in sub-
section (b). 
‘‘(b) ANNUAL REPORT.— 
‘‘(1) IN GENERAL.—With respect to plan years 
beginning on or after the date that is 3 years after 
the date of enactment of this section, for each such 
plan year, a group health plan or health insurance 
issuer offering group health insurance coverage, or 
an entity providing pharmacy benefits management 
services on behalf of such a plan or an issuer, shall 
submit to the plan sponsor (as defined in section 
3(16)(B)) of such plan or coverage a report in a ma-
chine-readable format. Each such report shall in-
clude, with respect to such plan or coverage provided 
for such plan year— 
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‘‘(A) to the extent feasible, information col-
lected from drug manufacturers (or an entity 
administering copay assistance on behalf of 
such manufacturers) by such plan or issuer (or 
entity or subsidiary providing pharmacy bene-
fits management services on behalf of such plan 
or issuer) on the total amount of copayment as-
sistance dollars paid, or copayment cards ap-
plied, that were funded by the drug manufac-
turer with respect to the participants, bene-
ficiaries, and enrollees in such plan or coverage; 
‘‘(B) a list of each drug covered by such 
plan or coverage that was dispensed during the 
plan year, including, with respect to each such 
drug during such plan year— 
‘‘(i) the brand name, chemical entity, 
and National Drug Code; 
‘‘(ii) the number of participants, bene-
ficiaries, and enrollees for whom the drug 
was dispensed during the plan year, the 
total number of prescription claims for the 
drug (including original prescriptions and 
refills), and the total number of dosage 
units of the drug dispensed across the plan 
year, disaggregated by dispensing channel 
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therapeutic category or class of drugs, during 
the plan year— 
‘‘(i) total gross spending by the plan 
or coverage, before manufacturer rebates, 
fees, or other manufacturer remuneration; 
‘‘(ii) the number of participants, bene-
ficiaries, and enrollees who were dispensed 
a drug covered by such plan or coverage in 
that category or class, broken down by 
each such drug (identified by National 
Drug Code); 
‘‘(iii) if applicable to that category or 
class, a description of the formulary tiers 
and utilization management (such as prior 
authorization or step therapy) employed 
for drugs in that category or class; and 
‘‘(iv) the total out-of-pocket spending 
by participants, beneficiaries, and enroll-
ees, including participant, beneficiary, and 
enrollee spending through copayments, co-
insurance, and deductibles; 
‘‘(D) total gross spending on prescription 
drugs by the plan or coverage during the plan 
year, before rebates and other manufacturer 
fees or remuneration; 
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‘‘(E) total amount received, or expected to 
be received, by the health plan or health insur-
ance coverage in drug manufacturer rebates, 
fees, alternative discounts, and all other remu-
neration received from the manufacturer or any 
third party, other than the plan sponsor, re-
lated to utilization of drug or drug spending 
under that health plan or health insurance cov-
erage during the plan year; 
‘‘(F) the total net spending on prescription 
drugs by the health plan or health insurance 
coverage during the plan year; and 
‘‘(G) amounts paid directly or indirectly in 
rebates, fees, or any other type of remuneration 
to brokers, consultants, advisors, or any other 
individual or firm for the referral of the group 
health plan’s or health insurance issuer’s busi-
ness to the pharmacy benefits manager. 
‘‘(2) PRIVACY REQUIREMENTS.—Health insur-
ance issuers offering group health insurance cov-
erage and entities providing pharmacy benefits man-
agement services on behalf of a group health plan 
shall provide information under paragraph (1) in a 
manner consistent with the privacy, security, and 
breach notification regulations promulgated under 
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section 264(c) of the Health Insurance Portability 
and Accountability Act of 1996, and shall restrict 
the use and disclosure of such information according 
to such privacy regulations. 
‘‘(3) DISCLOSURE AND REDISCLOSURE.— 
‘‘(A) LIMITATION
TO
BUSINESS
ASSOCI-
ATES.—A group health plan receiving a report 
under paragraph (1) may disclose such informa-
tion only to business associates of such plan as 
defined in section 160.103 of title 45, Code of 
Federal Regulations (or successor regulations). 
‘‘(B) CLARIFICATION REGARDING PUBLIC 
DISCLOSURE
OF
INFORMATION.—Nothing in 
this section prevents a health insurance issuer 
offering group health insurance coverage or an 
entity providing pharmacy benefits management 
services on behalf of a group health plan from 
placing reasonable restrictions on the public dis-
closure of the information contained in a report 
described in paragraph (1), except that such 
issuer or entity may not restrict disclosure of 
such report to the Department of Health and 
Human Services, the Department of Labor, the 
Department of the Treasury, the Comptroller 
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General of the United States, or applicable 
State agencies. 
‘‘(C) LIMITED
FORM
OF
REPORT.—The 
Secretary shall define through rulemaking a 
limited form of the report under paragraph (1) 
required of plan sponsors who are drug manu-
facturers, drug wholesalers, or other direct par-
ticipants in the drug supply chain, in order to 
prevent anti-competitive behavior. 
‘‘(4) REPORT TO GAO.—A group health plan or 
health insurance issuer offering group health insur-
ance coverage, or an entity providing pharmacy ben-
efits management services on behalf of a group 
health plan shall submit to the Comptroller General 
of the United States each of the first 4 reports sub-
mitted to a plan sponsor under paragraph (1) with 
respect to such coverage or plan, and other such re-
ports as requested, in accordance with the privacy 
requirements under paragraph (2), the disclosure 
and redisclosure standards under paragraph (3), the 
standards specified pursuant to paragraph (5), and 
such other information that the Comptroller General 
determines necessary to carry out the study under 
section 103(d) of the Health Care Price Trans-
parency Act of 2023. 
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‘‘(5) STANDARD FORMAT.—Not later than 18 
months after the date of enactment of this section, 
the Secretary shall specify through rulemaking 
standards for health insurance issuers and entities 
required to submit reports under paragraph (4) to 
submit such reports in a standard format. 
‘‘(c) ENFORCEMENT.— 
‘‘(1) IN
GENERAL.—Notwithstanding section 
502, the Secretary, in consultation with the Sec-
retary of Health and Human Services and the Sec-
retary of the Treasury, shall enforce this section. 
‘‘(2) FAILURE TO PROVIDE TIMELY INFORMA-
TION.—A health insurance issuer or an entity pro-
viding pharmacy benefits management services that 
violates subsection (a) or fails to provide information 
required under subsection (b) shall be subject to a 
civil monetary penalty in the amount of $10,000 for 
each day during which such violation continues or 
such information is not disclosed or reported. 
‘‘(3) FALSE INFORMATION.—A health insurance 
issuer or entity providing pharmacy benefits man-
agement services that knowingly provides false infor-
mation under this section shall be subject to a civil 
money penalty in an amount not to exceed $100,000 
for each item of false information. Such civil money 
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100 
penalty shall be in addition to other penalties as 
may be prescribed by law. 
‘‘(4) PROCEDURE.—The provisions of section 
1128A of the Social Security Act, other than sub-
section (a) and (b) and the first sentence of sub-
section (c)(1) of such section shall apply to civil 
monetary penalties under this subsection in the 
same manner as such provisions apply to a penalty 
or proceeding under section 1128A of the Social Se-
curity Act. 
‘‘(5) WAIVERS.—The Secretary may waive pen-
alties under paragraph (2), or extend the period of 
time for compliance with a requirement of this sec-
tion, for an entity in violation of this section that 
has made a good-faith effort to comply with this sec-
tion. 
‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to permit a health insurance issuer, 
group health plan, or other entity to restrict disclosure to, 
or otherwise limit the access of, the Secretary of Labor 
to a report described in subsection (b)(1) or information 
related to compliance with subsection (a) or (b) by such 
issuer, plan, or other entity subject to such subsections. 
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101 
‘‘(e) DEFINITION.—In this section, the term ‘whole-
sale acquisition cost’ has the meaning given such term in 
section 1847A(c)(6)(B) of the Social Security Act.’’; and 
(B) in section 502 (29 U.S.C. 1132)— 
(i) in subsection (a)— 
(I) in paragraph (6), by striking 
‘‘or (9)’’ and inserting ‘‘(9), or (13)’’; 
(II) in paragraph (10), by strik-
ing at the end ‘‘or’’; 
(III) in paragraph (11), at the 
end by striking the period and insert-
ing ‘‘; or’’; and 
(IV) by adding at the end the fol-
lowing new paragraph: 
‘‘(12) by the Secretary, in consultation with the 
Secretary of Health and Human Services, and the 
Secretary of the Treasury, to enforce section 726.’’; 
(ii) in subsection (b)(3), by inserting 
‘‘and subsections (a)(12) and (c)(13)’’ be-
fore ‘‘, the Secretary is not’’; and 
(iii) in subsection (c), by adding at 
the end the following new paragraph: 
‘‘(13) SECRETARIAL ENFORCEMENT AUTHORITY 
RELATING TO OVERSIGHT OF PHARMACY BENEFITS 
MANAGER SERVICES.— 
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103 
shall be in addition to other penalties as may 
be prescribed by law. 
‘‘(C) WAIVERS.—The Secretary may waive 
penalties under subparagraph (A), or extend 
the period of time for compliance with a re-
quirement of section 726, for an entity in viola-
tion of such section that has made a good-faith 
effort to comply with such section.’’. 
(2) CLERICAL AMENDMENT.—The table of con-
tents in section 1 of the Employee Retirement In-
come Security Act of 1974 (29 U.S.C. 1001 et seq.) 
is amended by inserting after the item relating to 
section 725 the following new item: 
‘‘Sec. 726. Oversight of pharmacy benefits manager services.’’. 
(d) GAO STUDY.— 
(1) IN GENERAL.—Not later than 3 years after 
the date of enactment of this Act, the Comptroller 
General of the United States shall submit to Con-
gress a report on— 
(A) pharmacy networks of group health 
plans, health insurance issuers, and entities 
providing pharmacy benefits management serv-
ices under such group health plan or group or 
individual health insurance coverage, including 
networks that have pharmacies that are under 
common ownership (in whole or part) with 
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104 
group health plans, health insurance issuers, or 
entities providing pharmacy benefits manage-
ment services or pharmacy benefits administra-
tive services under group health plan or group 
or individual health insurance coverage; 
(B) as it relates to pharmacy networks 
that include pharmacies under common owner-
ship described in subparagraph (A)— 
(i) whether such networks are de-
signed to encourage enrollees of a plan or 
coverage to use such pharmacies over other 
network pharmacies for specific services or 
drugs, and if so, the reasons the networks 
give for encouraging use of such phar-
macies; and 
(ii) whether such pharmacies are used 
by enrollees disproportionately more in the 
aggregate or for specific services or drugs 
compared to other network pharmacies; 
(C) whether group health plans and health 
insurance issuers offering group or individual 
health insurance coverage have options to elect 
different network pricing arrangements in the 
marketplace with entities that provide phar-
macy benefits management services, the preva-
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105 
lence of electing such different network pricing 
arrangements; 
(D) pharmacy network design parameters 
that encourage enrollees in the plan or coverage 
to fill prescriptions at mail order, specialty, or 
retail pharmacies that are wholly or partially- 
owned by that issuer or entity; and 
(E) the degree to which mail order, spe-
cialty, or retail pharmacies that dispense pre-
scription drugs to an enrollee in a group health 
plan or health insurance coverage that are 
under common ownership (in whole or part) 
with group health plans, health insurance 
issuers, or entities providing pharmacy benefits 
management services or pharmacy benefits ad-
ministrative services under group health plan or 
group or individual health insurance coverage 
receive reimbursement that is greater than the 
median price charged to the group health plan 
or health insurance issuer when the same drug 
is dispensed to enrollees in the plan or coverage 
by other pharmacies included in the pharmacy 
network of that plan, issuer, or entity that are 
not wholly or partially owned by the health in-
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106 
surance issuer or entity providing pharmacy 
benefits management services. 
(2) REQUIREMENT.—The Comptroller General 
of the United States shall ensure that the report 
under paragraph (1) does not contain information 
that would allow a reader to identify a specific plan 
or entity providing pharmacy benefits management 
services or otherwise contain commercial or financial 
information that is privileged or confidential. 
(3) DEFINITIONS.—In this subsection, the 
terms ‘‘group health plan’’, ‘‘health insurance cov-
erage’’, and ‘‘health insurance issuer’’ have the 
meanings given such terms in section 2791 of the 
Public Health Service Act (42 U.S.C. 300gg–91). 
SEC. 104. REPORTS ON HEALTH CARE TRANSPARENCY 
TOOLS AND DATA REQUIREMENTS. 
(a) INITIAL REPORT.—Not later than December 31, 
2024, the Comptroller General of the United States shall 
submit to the Committees (as defined in subsection (d)) 
an initial report that— 
(1) identifies and describes health care trans-
parency tools and Federal health care reporting re-
quirements (as described in subsection (d)) that are 
in effect as of the date of the submission of such ini-
tial report, including the frequency of reports with 
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107 
respect to each such requirement and whether any 
such requirements are duplicative; 
(2) reviews how such reporting requirements 
are enforced; 
(3) analyzes whether the public availability of 
health care transparency tools, and the publication 
of data pursuant to such reporting requirements, 
has— 
(A) been utilized and valued by consumers, 
including reasons for such utilization (or lack 
thereof); and 
(B) assisted health insurance plan spon-
sors and fiduciaries improve benefits, lower 
health care costs for plan participants, and 
meet fiduciary requirements; 
(4) includes recommendations to the Commit-
tees, the Secretary of Health and Human Services, 
the Secretary of Labor, and the Secretary of the 
Treasury to— 
(A) improve the efficiency, accuracy, and 
usability of health care transparency tools; 
(B) streamline Federal health care report-
ing requirements to eliminate duplicative re-
quirements and reduce the burden on entities 
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108 
required to submit reports pursuant to such 
provisions; 
(C) improve the accuracy and efficiency of 
such reports while maintaining the integrity 
and usability of the data provided by such re-
ports; 
(D) address any gaps in data provided by 
such reports; and 
(E) ensure that the data and information 
reported is comparable and usable to con-
sumers, including patients, plan sponsors, and 
policy makers. 
(b) FINAL REPORT.—Not later than December 31, 
2028, the Comptroller General of the United States shall 
submit to the Committees a report that includes— 
(1) the information provided in the initial re-
port, along with any updates to such information; 
and 
(2) any new information with respect to health 
care transparency tools that have been released fol-
lowing the submission of such initial report, or new 
reporting requirements in effect as of the date of the 
submission of the final report. 
(c) REPORT ON EXPANDING PRICE TRANSPARENCY 
REQUIREMENTS.—Not later than December 31, 2025, the 
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109 
Comptroller General of the United States, in consultation 
with the Secretary of Health and Human Services, health 
care provider groups, and patient advocacy groups, shall 
submit to the Committees a report that includes rec-
ommendations to expand price transparency reporting re-
quirements to additional care settings, with an emphasis 
on settings where shoppable services (as defined in sub-
section (d)) are furnished. 
(d) DEFINITIONS.—In this section: 
(1) COMMITTEES.—The term ‘‘Committees’’ 
means the Committee on Ways and Means, the 
Committee on Energy and Commerce, and the Com-
mittee on Education and the Workforce of the 
House of Representatives, and the Committee on Fi-
nance and the Committee on Health, Education, 
Labor, and Pensions of the Senate. 
(2) FEDERAL HEALTH CARE REPORTING RE-
QUIREMENTS.—The term ‘‘Federal health care re-
porting requirements’’ includes regulatory and statu-
tory requirements with respect to the reporting and 
publication of health care price, cost access, and 
quality data, including requirements established by 
the Consolidated Appropriations Act of 2021 (Public 
Law 116–260), this Act, and other reporting and 
publication requirements with respect to trans-
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110 
parency in health care as identified by the Comp-
troller General of the United States. 
(3) 
SHOPPABLE
SERVICE.—The 
term 
‘‘shoppable service’’ means a service that can be 
scheduled by a health care consumer in advance and 
includes all ancillary items and services customarily 
furnished as part of such service. 
SEC. 105. REPORT ON INTEGRATION IN MEDICARE. 
(a) REQUIRED MA AND PDP REPORTING.— 
(1) MA PLANS.—Section 1857(e) of the Social 
Security Act (42 U.S.C. 1395w–27(e)) is amended 
by adding at the end the following new paragraph: 
‘‘(6) REQUIRED DISCLOSURE OF CERTAIN IN-
FORMATION RELATING TO HEALTH CARE PROVIDER 
OWNERSHIP.— 
‘‘(A) IN GENERAL.—For plan year 2025 
and for every third plan year thereafter, each 
MA organization offering an MA plan under 
this part during such plan year shall submit to 
the Secretary, at a time and in a manner speci-
fied by the Secretary— 
‘‘(i) the taxpayer identification num-
ber for each health care provider that was 
a specified health care provider with re-
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111 
spect to such organization during such 
year; 
‘‘(ii) the total amount of incentive- 
based payments made to, and the total 
amount of shared losses recoupments col-
lected from, such specified health care pro-
viders during such plan year; and 
‘‘(iii) the total amount of incentive- 
based payments made to, and the total 
amount of shared losses recoupments col-
lected from, providers of services and sup-
pliers not described in clause (ii) during 
such plan year. 
‘‘(B) DEFINITION.—For purposes of this 
paragraph, the term ‘specified health care pro-
vider’ means, with respect to an MA organiza-
tion and a plan year, a provider of services or 
supplier with respect to which such organization 
(or any person with an ownership or control in-
terest (as defined in section 1124(a)(3)) in such 
organization) is a person with an ownership or 
control interest (as so defined).’’. 
(2) 
PRESCRIPTION
DRUG
PLANS.—Section 
1860D–12(b) of the Social Security Act (42 U.S.C. 
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1395w–112(b)) is amended by adding at the end the 
following new paragraph: 
‘‘(9) PROVISION OF INFORMATION RELATING TO 
PHARMACY OWNERSHIP.— 
‘‘(A) IN GENERAL.—For plan year 2025 
and for every third plan year thereafter, each 
PDP sponsor offering a prescription drug plan 
under this part during such plan year shall sub-
mit to the Secretary, at a time and in a manner 
specified by the Secretary, the taxpayer identi-
fication number and National Provider Identi-
fier for each pharmacy that was a specified 
pharmacy with respect to such sponsor during 
such year. 
‘‘(B) DEFINITION.—For purposes of this 
paragraph, 
the 
term 
‘specified 
pharmacy’ 
means, with respect to an PDP sponsor offering 
a prescription drug plan and a plan year, a 
pharmacy with respect to which— 
‘‘(i) such sponsor (or any person with 
an ownership or control interest (as de-
fined in section 1124(a)(3)) in such spon-
sor) is a person with an ownership or con-
trol interest (as so defined); or 
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‘‘(ii) a pharmacy benefit manager of-
fering services under such plan (or any 
person with an ownership or control inter-
est (as so defined) in such sponsor) is a 
person with an ownership or control inter-
est (as so defined).’’. 
(b) MEDPAC REPORTS.—Part E of title XVIII of the 
Social Security Act (42 U.S.C. 1395x et seq.), as amended 
by section 101, is further amended by adding at the end 
the following new section: 
‘‘SEC. 1899D. REPORTS ON VERTICAL INTEGRATION UNDER 
MEDICARE. 
‘‘(a) IN GENERAL.—Not later than June 15, 2029, 
and every 3 years thereafter, the Medicare Payment Advi-
sory Commission shall submit to Congress a report on the 
state of vertical integration in the health care sector dur-
ing the applicable year with respect to entities partici-
pating in the Medicare program, including health care pro-
viders, pharmacies, prescription drug plan sponsors, Medi-
care Advantage organizations, and pharmacy benefit man-
agers. Such report shall include— 
‘‘(1) with respect to Medicare Advantage orga-
nizations, the evaluation described in subsection (b); 
‘‘(2) with respect to prescription drug plans, 
pharmacy benefit managers, and pharmacies, the 
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comparisons and evaluations described in subsection 
(c); 
‘‘(3) with respect to Medicare Advantage plans 
under which benefits are available for physician-ad-
ministered drugs, the information described in sub-
section (d); and 
‘‘(4) the identifications described in subsection 
(e); and 
‘‘(5) an analysis of the impact of such integra-
tion on health care access, price, quality, and out-
comes. 
‘‘(b) MEDICARE ADVANTAGE ORGANIZATIONS.—For 
purposes of subsection (a)(1), the evaluation described in 
this subsection is, with respect to Medicare Advantage or-
ganizations and an applicable year, an evaluation, taking 
into account patient acuity and the types of areas serviced 
by such organization, of— 
‘‘(1) the average number of qualifying diag-
noses made during such year with respect to enroll-
ees of a Medicare Advantage plan offered by such 
organization who, during such year, received a 
health risk assessment from a specified health care 
provider; 
‘‘(2) the average risk score for such enrollees 
who received such an assessment during such year; 
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‘‘(4) To the extent that the available data per-
mits, an evaluation of fees charged by rebate 
aggregators that are affiliated with plan sponsors. 
‘‘(d) PHYSICIAN-ADMINISTERED DRUGS.—For pur-
poses of subsection (a)(3), the information described in 
this subsection is, with respect to physician-administered 
drugs for which benefits are available under a Medicare 
Advantage plan during an applicable year, the following: 
‘‘(1) With respect to each such plan, an identi-
fication of each drug for which benefits were avail-
able under such plan only when administered by a 
health care provider that acquired such drug from 
an affiliated pharmacy. 
‘‘(2) An evaluation of the difference between 
the total number of drugs administered by a health 
care provider that were acquired from affiliated 
pharmacies compared to the number of such drugs 
so administered that were acquired from pharmacies 
other than affiliated pharmacies, and an evaluation 
of the difference in payments for such drugs so ad-
ministered when acquired from a specified pharmacy 
and when acquired from a pharmacy that is not a 
specified pharmacy. 
‘‘(3) An evaluation of the dollar value of all 
such drugs that were not so administered because of 
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a delay attributable to an affiliated pharmacy com-
pared to the dollar value of all such drugs that were 
not so administered because of a delay attributable 
to pharmacy that is not an affiliated pharmacy. 
‘‘(4) The number of enrollees administered such 
a drug that was acquired from an affiliated phar-
macy. 
‘‘(5) The number of enrollees furnished such a 
drug that was acquired from a pharmacy that is not 
an affiliated pharmacy. 
‘‘(e) IDENTIFICATIONS.—For purposes of subsection 
(a)(4), the identifications described in this subsection are, 
with respect to an applicable year, identifications of each 
health care entity participating under the Medicare pro-
gram with respect to which another health care entity so 
participating is a person with an ownership or control in-
terest (as defined in section 1124(a)(3)). 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) AFFILIATED PHARMACY.—The term ‘affili-
ated pharmacy’ means, with respect to a Medicare 
Advantage plan offered by a Medicare Advantage or-
ganization, a pharmacy with respect to which such 
organization (or any person with an ownership or 
control interest (as defined in section 1124(a)(3)) in 
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such organization) is a person with an ownership or 
control interest (as so defined). 
‘‘(2) APPLICABLE YEAR.—The term ‘applicable 
year’ means, with respect to a report submitted 
under subsection (a), the first calendar year begin-
ning at least 4 years prior to the date of the submis-
sion of such report. 
‘‘(3) COVERED PART D DRUG.—The term ‘cov-
ered part D drug’ has the meaning given such term 
in section 1860D–2(e). 
‘‘(4) DIRECT AND INDIRECT REMUNERATION.— 
The term ‘direct and indirect remuneration’ has the 
meaning given such term in section 423.308 of title 
42, Code of Federal Regulations (or any successor 
regulation). 
‘‘(5) QUALIFYING DIAGNOSIS.—The term ‘quali-
fying diagnosis’ means, with respect to an enrollee of 
a Medicare Advantage plan, a diagnosis that is 
taken into account in calculating a risk score for 
such enrollee under the risk adjustment methodology 
established by the Secretary pursuant to section 
1853(a)(3). 
‘‘(6) RISK
SCORE.—The term ‘risk score’ 
means, with respect to an enrollee of a Medicare Ad-
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vantage plan, the score calculated for such individual 
using the methodology described in paragraph (5). 
‘‘(7) PHYSICIAN-ADMINISTERED
DRUG.—The 
term ‘physician-administered drug’ means a drug 
furnished to an individual that, had such individual 
been enrolled under part B and not enrolled under 
part C, would have been payable under section 
1842(o). 
‘‘(8) SPECIFIED
HEALTH
CARE
PROVIDER.— 
The term ‘specified health care provider’ means, 
with respect to a Medicare Advantage plan offered 
by a Medicare Advantage organization, a health care 
provider with respect to which such organization (or 
any person with an ownership or control interest (as 
defined in section 1124(a)(3)) in such organization) 
is a person with an ownership or control interest (as 
so defined). 
‘‘(9) SPECIFIED PHARMACY.—The term ‘speci-
fied pharmacy’ means, with respect to a prescription 
drug plan offered by a prescription drug plan spon-
sor, a pharmacy with respect to which— 
‘‘(A) such sponsor (or any person with an 
ownership or control interest (as defined in sec-
tion 1124(a)(3)) in such sponsor) is a person 
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with an ownership or control interest (as so de-
fined); or 
‘‘(B) a pharmacy benefit manager offering 
services under such plan (or any person with an 
ownership or control interest (as so defined) in 
such sponsor) is a person with an ownership or 
control interest (as so defined). 
‘‘(10) SPECIFIED
PHARMACY
BENEFIT
MAN-
AGER.—The term ‘specified pharmacy benefit man-
ager’ means, with respect to a prescription drug 
plan offered by a prescription drug plan sponsor, a 
pharmacy benefit manager with respect to which 
such sponsor (or any person with an ownership or 
control interest (as defined in section 1124(a)(3)) in 
such sponsor) is a person with an ownership or con-
trol interest (as so defined).’’. 
TITLE II—FAIR PRICES FOR 
PATIENTS 
SEC. 201. LIMITATION ON COST SHARING TO NET PRICE 
AMOUNT UNDER MEDICARE PART D. 
(a) IN GENERAL.—Section 1860D–2 of the Social 
Security Act (42 U.S.C. 1395w–102) is amended— 
(1) in subsection (b)— 
(A) in paragraph (2)(A), by striking ‘‘(8) 
and (9)’’ and inserting ‘‘(8), (9), and (10)’’; 
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(B) in paragraph (9)(B)(ii), by striking 
‘‘For a plan year’’ and inserting ‘‘Subject to 
paragraph (10), for a plan year’’; and 
(C) by adding at the end the following new 
paragraph: 
‘‘(10) LIMITATION ON COST SHARING TO NET 
PRICE AMOUNT.— 
‘‘(A) IN GENERAL.—For a plan year begin-
ning on or after January 1, 2027, the coverage 
provides benefits for a supply of a covered part 
D drug dispensed by a pharmacy, for costs in 
excess of the deductible specified in paragraph 
(1) and prior to an individual reaching the out- 
of-pocket threshold under paragraph (4), with 
cost-sharing for a month’s supply that does not 
exceed the average net price for such a supply 
of such drug during such plan year (or, if 
lower, the applicable cash price for such a sup-
ply of such drug so dispensed by such phar-
macy). 
‘‘(B) DEFINITIONS.—In this paragraph: 
‘‘(i) APPLICABLE
CASH
PRICE.—The 
term ‘applicable cash price’ means, with 
respect to a supply of a covered part D 
drug dispensed by a pharmacy, the price 
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