I 
118TH CONGRESS 
1ST SESSION H. R. 4507 
To amend the Employee Retirement Income Security Act of 1974 to promote 
transparency in health coverage and reform pharmacy benefit manage-
ment services with respect to group health plans, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 10, 2023 
Mr. GOOD of Virginia (for himself and Mr. DESAULNIER) introduced the fol-
lowing bill; which was referred to the Committee on Education and the 
Workforce, and in addition to the Committees on Energy and Commerce, 
and Ways and Means, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall within 
the jurisdiction of the committee concerned 
A BILL 
To amend the Employee Retirement Income Security Act 
of 1974 to promote transparency in health coverage and 
reform pharmacy benefit management services with re-
spect to group health plans, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Transparency in Cov-
erage Act of 2023’’. 
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SEC. 2. PROMOTING GROUP HEALTH PLAN AND GROUP 
HEALTH 
INSURANCE 
COVERAGE 
PRICE 
TRANSPARENCY. 
(a) IN GENERAL.— 
(1) ERISA.— 
(A) IN GENERAL.—Section 719 of the Em-
ployee Retirement Income Security Act of 1974 
(29 U.S.C. 1185h) is amended to read as fol-
lows: 
‘‘SEC. 719. PRICE TRANSPARENCY REQUIREMENTS. 
‘‘(a) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group health insurance 
coverage, shall make available to the public accurate and 
timely disclosures of the following information: 
‘‘(1) Claims payment policies and practices. 
‘‘(2) Periodic financial disclosures. 
‘‘(3) Data on enrollment. 
‘‘(4) Data on disenrollment. 
‘‘(5) Data on the number of claims that are de-
nied. 
‘‘(6) Data on rating practices. 
‘‘(7) Information on cost-sharing and payments 
with respect to any out-of-network coverage (or with 
respect to any item and service furnished under such 
a plan or such group health insurance coverage that 
does not use a network of providers). 
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‘‘(8) Information on participant and beneficiary 
rights under this part. 
‘‘(9) Rate and payment information described 
in subsection (d). 
‘‘(10) Other information as determined appro-
priate by the Secretary. 
Rate and payment information described in paragraph (9) 
shall be made available to the public not later than Janu-
ary 10, 2025, and not later than the tenth day of every 
month thereafter, in the manner described in subsection 
(d)(2)(A), and, beginning on January 1, 2027, in real-time 
through an application program interface (or successor 
technology) described in subsection (d)(2)(B). 
‘‘(b) USE OF PLAIN LANGUAGE.—The information 
required to be submitted under subsection (a) shall be pro-
vided in plain language. The term ‘plain language’ means 
language that the intended audience, including individuals 
with limited English proficiency, can readily understand 
and use because that language is clear, concise, well-orga-
nized, accurately describes the information, and follows 
other best practices of plain language writing. The Sec-
retary, jointly with the Secretary of Health and Human 
Services and the Secretary of Labor, shall develop and 
issue standards for plain language writing for purposes 
of this section and shall develop a standardized reporting 
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template and standardized definitions of terms to allow 
for comparison across group health plans and health in-
surance coverage. 
‘‘(c) COST SHARING TRANSPARENCY.— 
‘‘(1) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group health insur-
ance coverage, shall, upon request of a participant 
or beneficiary and in a timely manner, provide to the 
participant or beneficiary a statement of the amount 
of cost-sharing (including deductibles, copayments, 
and coinsurance) under the participant’s or bene-
ficiary’s plan or coverage that the participant or 
beneficiary would be responsible for paying with re-
spect to the furnishing of a specific item or service 
by a provider. At a minimum, such information shall 
include the information specified in paragraph (2) 
and shall be made available at no cost to the partici-
pant or beneficiary through a self-service tool that 
meets the requirements of paragraph (3) or through 
a paper or phone disclosure, at the option of the 
participant or beneficiary, that meets such require-
ments as the Secretary may specify. 
‘‘(2) SPECIFIED INFORMATION.—For purposes 
of paragraph (1), the information specified in this 
paragraph is, with respect to an item or service for 
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which benefits are available under a group health 
plan or group health insurance coverage (as applica-
ble) furnished by a health care provider to a partici-
pant or beneficiary of such plan or coverage, the fol-
lowing: 
‘‘(A) If such provider is a participating 
provider with respect to such item or service, 
the in-network rate (as defined in subsection 
(f)) for such item or service and for any other 
item or service that is inherent in the fur-
nishing of the item or service that is the subject 
of such request. 
‘‘(B) If such provider is not a participating 
provider, the allowed amount, percentage of 
billed charges, or other rate that such plan or 
coverage will recognize as payment for such 
item or service, along with a notice that such 
individual may be liable for additional charges 
billed by such provider. 
‘‘(C) The estimated amount of cost sharing 
(including deductibles, copayments, and coin-
surance) that the participant or beneficiary will 
incur for such item or service (which, in the 
case such item or service is to be furnished by 
a provider described in subparagraph (B), shall 
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be calculated using the amount or rate de-
scribed in such subparagraph (or, in the case 
such plan or issuer uses a percentage of billed 
charges to determined the amount of payment 
for such provider, using a reasonable estimate 
of such percentage of such charges)). 
‘‘(D) The amount the participant or bene-
ficiary has already accumulated with respect to 
any deductible or out of pocket maximum under 
the plan or coverage (broken down, in the case 
separate deductibles or maximums apply to sep-
arate participants and beneficiaries enrolled in 
the plan or coverage, by such separate 
deductibles or maximums, in addition to any 
cumulative deductible or maximum). 
‘‘(E) Any shared savings or other benefit 
available to the participant or beneficiary with 
respect to such item or service. 
‘‘(F) In the case such plan or coverage im-
poses any frequency or volume limitations with 
respect to such item or service (excluding med-
ical necessity determinations), the amount that 
such participant or beneficiary has accrued to-
wards such limitation with respect to such item 
or service. 
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‘‘(G) Any prior authorization, concurrent 
review, step therapy, fail first, or similar re-
quirements applicable to coverage of such item 
or service under such plan or group health in-
surance coverage. 
‘‘(3) SELF-SERVICE
TOOL.—For purposes of 
paragraph (1), a self-service tool established by a 
group health plan or health insurance issuer offering 
group health insurance coverage meets the require-
ments of this paragraph if such tool— 
‘‘(A) is based on an Internet website, mo-
bile application, or other platform determined 
appropriate by the Secretary; 
‘‘(B) provides for real-time responses to re-
quests described in paragraph (1); 
‘‘(C) is updated in a manner such that in-
formation provided through such tool is accu-
rate at the time such request is made; 
‘‘(D) allows such a request to be made 
with respect to an item or service furnished 
by— 
‘‘(i) a specific provider that is a par-
ticipating provider with respect to such 
item or service; 
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‘‘(ii) all providers that are partici-
pating providers with respect to such plan 
and such item or service for purposes of 
facilitating price comparisons; or 
‘‘(iii) a provider that is not described 
in clause (ii); and 
‘‘(E) provides that such a request may be 
made with respect to an item or service through 
use of the billing code for such item or service 
or through use of a descriptive term for such 
item or service. 
The Secretary may require such tool, as a condition 
of complying with subparagraph (E), to link multiple 
billing codes to a single descriptive term if the Sec-
retary determines that the billing codes to be so 
linked correspond to items and services. 
‘‘(4) PROVIDER TOOL.—A group health plan, 
and a health insurance issuer offering group health 
insurance coverage, shall permit providers to learn 
the amount of cost-sharing (including deductibles, 
copayments, and coinsurance) that would apply 
under an individual’s plan or coverage that the indi-
vidual would be responsible for paying with respect 
to the furnishing of a specific item or service by an-
other provider in a timely manner upon the request 
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of the provider and with the consent of such indi-
vidual in the same manner and to the same extent 
as if such request has been made by such individual. 
As part of any tool used to facilitate such requests 
from a provider, such plan or issuer offering health 
insurance coverage may include functionality that— 
‘‘(A) allows providers to submit the notifi-
cations to such plan or coverage required under 
section 2799B–6 of the Public Health Service 
Act; and 
‘‘(B) provides for notifications required 
under section 716(f) to such an individual. 
‘‘(d) RATE AND PAYMENT INFORMATION.— 
‘‘(1) IN GENERAL.—For purposes of subsection 
(a)(9), the rate and payment information described 
in this subsection is, with respect to a group health 
plan or group health insurance coverage (as applica-
ble), the following: 
‘‘(A) With respect to each item or service 
(other than a drug) for which benefits are avail-
able under such plan or coverage, the in-net-
work rate (in a dollar amount) in effect as of 
the first day of the plan year during which such 
information is submitted with each provider 
(identified by national provider identifier) that 
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is a participating provider with respect to such 
item or service (or, in the case such rate is not 
available in a dollar amount, such formulae, 
pricing methodologies, or other information 
used to calculate such rate). 
‘‘(B) With respect to each dosage form and 
indication of each drug (identified by national 
drug code) for which benefits are available 
under such plan or coverage— 
‘‘(i) the in-network rate (in a dollar 
amount) in effect as of the first day of the 
plan year during which such information is 
submitted with each provider (identified by 
national provider identifier) that is a par-
ticipating provider with respect to such 
drug (or, in the case such rate is not avail-
able in a dollar amount, such formulae, 
pricing methodologies, or other information 
used to calculate such rate); and 
‘‘(ii) the average amount paid by such 
plan (net of rebates, discounts, and price 
concessions) for such drug dispensed or 
administered during the 90-day period be-
ginning 180 days before such date of sub-
mission to each provider that was a par-
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ticipating provider with respect to such 
drug, broken down by each such provider 
(identified by national provider identifier), 
other than such an amount paid to a pro-
vider that, during such period, submitted 
fewer than 20 claims for such drug to such 
plan or coverage. 
‘‘(C) With respect to each item or service 
for which benefits are available under such plan 
or coverage, the amount billed, and the amount 
allowed by the plan or coverage, for each such 
item or service furnished during the 90-day pe-
riod specified in subparagraph (B) by a pro-
vider that was not a participating provider with 
respect to such item or service, broken down by 
each such provider (identified by national pro-
vider identifier), other than items and services 
with respect to which fewer than 20 claims for 
such item or service were submitted to such 
plan or coverage during such period. 
Such rate and payment information shall be made 
available with respect to each individual item or 
service, regardless of whether such item or service is 
paid for as part of a bundled payment, episode of 
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care, value-based payment arrangement, or other-
wise. 
‘‘(2) MANNER OF PUBLICATION.— 
‘‘(A) IN GENERAL.—Rate and payment in-
formation required to be made available under 
subsection (a)(9) shall be so made available in 
dollar amounts through 3 separate machine- 
readable files corresponding to the information 
described in each of subparagraphs (A) through 
(C) of paragraph (1) that meet such require-
ments as specified by the Secretary not later 
than 180 days after the date of the enactment 
of this paragraph through rulemaking. Such re-
quirements shall ensure that such files are lim-
ited to an appropriate size, do not include infor-
mation that is duplicative of information con-
tained in the same file or in other files made 
available under such subsection, are made avail-
able in a widely-available format that allows for 
information contained in such files to be com-
pared across group health plans and group 
health insurance coverage, and are accessible to 
individuals at no cost and without the need to 
establish a user account or provide other cre-
dentials. 
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‘‘(B) REAL-TIME PROVISION OF INFORMA-
TION.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), beginning January 1, 2026, rate and 
payment information required to be made 
available by a group health plan or health 
insurance issuer under subsection (a)(9) 
shall, in addition to being made available 
in the manner described in subparagraph 
(A), be made available through an applica-
tion program interface (or successor tech-
nology) that provides access to such infor-
mation in real time and that meets such 
technical standards as may be specified by 
the Secretary. 
‘‘(ii) EXEMPTION FOR CERTAIN PLANS 
OR COVERAGE.—Clause (i) shall not apply 
with respect to information described in 
such clause required to be made available 
by a group health plan or health insurance 
issuer offering health insurance coverage if 
such plan or coverage, as applicable, pro-
vides benefits for fewer than 500 partici-
pants and beneficiaries. 
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‘‘(3) USER GUIDE.—The Secretary, Secretary 
of Health and Human Services, and Secretary of the 
Treasury shall jointly make available to the public 
instructions written in plain language explaining how 
individuals may search for information described in 
paragraph (1) in files submitted in accordance with 
paragraph (2). 
‘‘(4) ANNUAL SUMMARY.—For each year (be-
ginning with 2025), each group health plan and 
health insurance issuer offering group health insur-
ance coverage shall make public a machine-readable 
file meeting such standards as established by the 
Secretary under paragraph (2) containing a sum-
mary of all rate and payment information made pub-
lic by such plan or issuer with respect to such plan 
or coverage during such year (such as averages of all 
such information so made public). 
‘‘(e) ATTESTATION.—Each group health plan and 
health insurance issuer offering group health insurance 
coverage shall annually submit to the Secretary an attesta-
tion of such plan’s or such coverage’s compliance with the 
provisions of this section along with a link to disclosures 
made in accordance with subsection (a). 
‘‘(f) DEFINITIONS.—In this subsection: 
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‘‘(1) PARTICIPATING
PROVIDER.—The term 
‘participating provider’ has the meaning given such 
term in section 716 and includes a participating fa-
cility. 
‘‘(2) IN-NETWORK
RATE.—The term ‘in-net-
work rate’ means, with respect to a group health 
plan or group health insurance coverage and an item 
or service furnished by a provider that is a partici-
pating provider with respect to such plan or cov-
erage and item or service, the contracted rate (re-
flected as a dollar amount) in effect between such 
plan or coverage and such provider for such item or 
service.’’. 
(B) CLERICAL AMENDMENT.—The table of 
contents in section 1 of such Act is amended by 
striking the item relating to section 719 and in-
serting the following new item: 
‘‘Sec. 719. Price transparency requirements.’’. 
(2) IRC.— 
(A) IN GENERAL.—Section 9819 of the In-
ternal Revenue Code of 1986 is amended to 
read as follows: 
‘‘SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS. 
‘‘(a) IN GENERAL.—A group health plan shall make 
available to the public accurate and timely disclosures of 
the following information: 
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‘‘(1) Claims payment policies and practices. 
‘‘(2) Periodic financial disclosures. 
‘‘(3) Data on enrollment. 
‘‘(4) Data on disenrollment. 
‘‘(5) Data on the number of claims that are de-
nied. 
‘‘(6) Data on rating practices. 
‘‘(7) Information on cost-sharing and payments 
with respect to any out-of-network coverage (or with 
respect to any item and service furnished under such 
a plan that does not use a network of providers). 
‘‘(8) Information on participant and beneficiary 
rights under this part. 
‘‘(9) Rate and payment information described 
in subsection (d). 
‘‘(10) Other information as determined appro-
priate by the Secretary. 
Rate and payment information described in paragraph (9) 
shall be made available to the public not later than Janu-
ary 10, 2025, and not later than the tenth day of every 
month thereafter, in the manner described in subsection 
(d)(2)(A), and, beginning on January 1, 2027, in real-time 
through an application program interface (or successor 
technology) described in subsection (d)(2)(B). 
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‘‘(b) USE OF PLAIN LANGUAGE.—The information 
required to be submitted under subsection (a) shall be pro-
vided in plain language. The term ‘plain language’ means 
language that the intended audience, including individuals 
with limited English proficiency, can readily understand 
and use because that language is clear, concise, well-orga-
nized, accurately describes the information, and follows 
other best practices of plain language writing. The Sec-
retary, jointly with the Secretary of Health and Human 
Services and the Secretary of Labor, shall develop and 
issue standards for plain language writing for purposes 
of this section and shall develop a standardized reporting 
template and standardized definitions of terms to allow 
for comparison across group health plans and health in-
surance coverage. 
‘‘(c) COST SHARING TRANSPARENCY.— 
‘‘(1) IN GENERAL.—A group health plan shall, 
upon request of a participant or beneficiary and in 
a timely manner, provide to the participant or bene-
ficiary a statement of the amount of cost-sharing 
(including deductibles, copayments, and coinsurance) 
under the participant’s or beneficiary’s plan that the 
participant or beneficiary would be responsible for 
paying with respect to the furnishing of a specific 
item or service by a provider. At a minimum, such 
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information shall include the information specified in 
paragraph (2) and shall be made available at no cost 
to the participant or beneficiary through a self-serv-
ice tool that meets the requirements of paragraph 
(3) or through a paper or phone disclosure, at the 
option of the participant or beneficiary, that meets 
such requirements as the Secretary may specify. 
‘‘(2) SPECIFIED INFORMATION.—For purposes 
of paragraph (1), the information specified in this 
paragraph is, with respect to an item or service for 
which benefits are available under a group health 
plan furnished by a health care provider to a partici-
pant or beneficiary of such plan, the following: 
‘‘(A) If such provider is a participating 
provider with respect to such item or service, 
the in-network rate (as defined in subsection 
(f)) for such item or service and for any other 
item or service that is inherent in the fur-
nishing of the item or service that is the subject 
of such request. 
‘‘(B) If such provider is not a participating 
provider, the allowed amount, percentage of 
billed charges, or other rate that such plan will 
recognize as payment for such item or service, 
along with a notice that such individual may be 
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liable for additional charges billed by such pro-
vider. 
‘‘(C) The estimated amount of cost sharing 
(including deductibles, copayments, and coin-
surance) that the participant or beneficiary will 
incur for such item or service (which, in the 
case such item or service is to be furnished by 
a provider described in subparagraph (B), shall 
be calculated using the amount or rate de-
scribed in such subparagraph (or, in the case 
such plan uses a percentage of billed charges to 
determined the amount of payment for such 
provider, using a reasonable estimate of such 
percentage of such charges)). 
‘‘(D) The amount the participant or bene-
ficiary has already accumulated with respect to 
any deductible or out of pocket maximum under 
the plan (broken down, in the case separate 
deductibles or maximums apply to separate par-
ticipants and beneficiaries enrolled in the plan, 
by such separate deductibles or maximums, in 
addition to any cumulative deductible or max-
imum). 
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‘‘(E) Any shared savings or other benefit 
available to the participant or beneficiary with 
respect to such item or service. 
‘‘(F) In the case such plan imposes any 
frequency or volume limitations with respect to 
such item or service (excluding medical neces-
sity determinations), the amount that such par-
ticipant or beneficiary has accrued towards such 
limitation with respect to such item or service. 
‘‘(G) Any prior authorization, concurrent 
review, step therapy, fail first, or similar re-
quirements applicable to coverage of such item 
or service under such plan. 
‘‘(3) SELF-SERVICE
TOOL.—For purposes of 
paragraph (1), a self-service tool established by a 
group health plan meets the requirements of this 
paragraph if such tool— 
‘‘(A) is based on an Internet website, mo-
bile application, or other platform determined 
appropriate by the Secretary; 
‘‘(B) provides for real-time responses to re-
quests described in paragraph (1); 
‘‘(C) is updated in a manner such that in-
formation provided through such tool is accu-
rate at the time such request is made; 
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insurance) that would apply under an individual’s 
plan that the individual would be responsible for 
paying with respect to the furnishing of a specific 
item or service by another provider in a timely man-
ner upon the request of the provider and with the 
consent of such individual in the same manner and 
to the same extent as if such request has been made 
by such individual. As part of any tool used to facili-
tate such requests from a provider, such plan may 
include functionality that— 
‘‘(A) allows providers to submit the notifi-
cations to such plan or coverage required under 
section 2799B–6 of the Public Health Services 
Act; and 
‘‘(B) provides for notifications required 
under section 9816(f) to such an individual. 
‘‘(d) RATE AND PAYMENT INFORMATION.— 
‘‘(1) IN GENERAL.—For purposes of subsection 
(a)(9), the rate and payment information described 
in this subsection is, with respect to a group health 
plan, the following: 
‘‘(A) With respect to each item or service 
(other than a drug) for which benefits are avail-
able under such plan, the in-network rate (in a 
dollar amount) in effect as of the first day of 
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the plan year during which such information is 
submitted with each provider (identified by na-
tional provider identifier) that is a participating 
provider with respect to such item or service 
(or, in the case such rate is not available in a 
dollar amount, such formulae, pricing meth-
odologies, or other information used to calculate 
such rate). 
‘‘(B) With respect to each dosage form and 
indication of each drug (identified by national 
drug code) for which benefits are available 
under such plan— 
‘‘(i) the in-network rate (in a dollar 
amount) in effect as of the first day of the 
plan year during which such information is 
submitted with each provider (identified by 
national provider identifier) that is a par-
ticipating provider with respect to such 
drug (or, in the case such rate is not avail-
able in a dollar amount, such formulae, 
pricing methodologies, or other information 
used to calculate such rate); and 
‘‘(ii) the average amount paid by such 
plan (net of rebates, discounts, and price 
concessions) for such drug dispensed or 
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administered during the 90-day period be-
ginning 180 days before such date of sub-
mission to each provider that was a par-
ticipating provider with respect to such 
drug, broken down by each such provider 
(identified by national provider identifier), 
other than such an amount paid to a pro-
vider that, during such period, submitted 
fewer than 20 claims for such drug to such 
plan or coverage. 
‘‘(C) With respect to each item or service 
for which benefits are available under such 
plan, the amount billed, and the amount al-
lowed by the plan, for each such item or service 
furnished during the 90-day period specified in 
subparagraph (B) by a provider that was not a 
participating provider with respect to such item 
or service, broken down by each such provider 
(identified by national provider identifier), other 
than items and services with respect to which 
fewer than 20 claims for such item or service 
were submitted to such plan or coverage during 
such period. 
Such rate and payment information shall be made 
available with respect to each individual item or 
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service, regardless of whether such item or service is 
paid for as part of a bundled payment, episode of 
care, value-based payment arrangement, or other-
wise. 
‘‘(2) MANNER OF PUBLICATION.— 
‘‘(A) IN GENERAL.—Rate and payment in-
formation required to be made available under 
subsection (a)(9) shall be so made available in 
dollar amounts through 3 separate machine- 
readable files corresponding to the information 
described in each of subparagraphs (A) through 
(C) of paragraph (1) that meet such require-
ments as specified by the Secretary not later 
than 180 days after the date of the enactment 
of this paragraph through rulemaking. Such re-
quirements shall ensure that such files are lim-
ited to an appropriate size, do not include infor-
mation that is duplicative of information con-
tained in other files made available under such 
subsection, are made available in a widely-avail-
able format that allows for information con-
tained in such files to be compared across 
group health plans, and are accessible to indi-
viduals at no cost and without the need to es-
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tablish a user account or provide other creden-
tials. 
‘‘(B) REAL-TIME PROVISION OF INFORMA-
TION.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), beginning January 1, 2026, rate and 
payment information required to be made 
available by a group health plan under 
subsection (a)(9) shall, in addition to being 
made available in the manner described in 
subparagraph (A), be made available 
through an application program interface 
(or successor technology) that provides ac-
cess to such information in real time and 
that meets such technical standards as 
may be specified by the Secretary. 
‘‘(ii) EXEMPTION FOR CERTAIN PLANS 
AND
COVERAGE.—Clause (i) shall not 
apply with respect to information described 
in such clause required to be made avail-
able by a group health plan if such plan 
provides benefits for fewer than 500 par-
ticipants and beneficiaries. 
‘‘(3) USER GUIDE.—The Secretary, Secretary 
of Health and Human Services, and Secretary of 
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Labor shall jointly make available to the public in-
structions written in plain language explaining how 
individuals may search for information described in 
paragraph (1) in files submitted in accordance with 
paragraph (2). 
‘‘(4) ANNUAL SUMMARY.—For each year (be-
ginning with 2025), each group health plan shall 
make public a machine-readable file meeting such 
standards as established by the Secretary under 
paragraph (2) containing a summary of all rate and 
payment information made public by such plan with 
respect to such plan or coverage during such year 
(such as averages of all such information so made 
public). 
‘‘(e) ATTESTATION.—Each group health plan shall 
annually submit to the Secretary an attestation of such 
plan’s compliance with the provisions of this section along 
with a link to disclosures made in accordance with sub-
section (a). 
‘‘(f) DEFINITIONS.—In this subsection: 
‘‘(1) PARTICIPATING
PROVIDER.—The term 
‘participating provider’ has the meaning given such 
term in section 9816 and includes a participating fa-
cility. 
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‘‘(2) IN-NETWORK
RATE.—The term ‘in-net-
work rate’ means, with respect to a group health 
plan and an item or service furnished by a provider 
that is a participating provider with respect to such 
plan and item or service, the contracted rate (re-
flected as a dollar amount) in effect between such 
plan and such provider for such item or service.’’. 
(B) CLERICAL AMENDMENT.—The item re-
lating to section 9819 in the table of sections 
for subchapter B of chapter 100 of the Internal 
Revenue Code of 1986 is amended to read as 
follows: 
‘‘Sec. 9819. Price transparency requirements.’’. 
(3) PHSA.—Section 2799A–4 of the Public 
Health Service Act (42 U.S.C. 300gg–114) is 
amended to read as follows: 
‘‘SEC. 2799A–4. PRICE TRANSPARENCY REQUIREMENTS. 
‘‘(a) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group or individual health 
insurance coverage, shall make available to the public ac-
curate and timely disclosures of the following information: 
‘‘(1) Claims payment policies and practices. 
‘‘(2) Periodic financial disclosures. 
‘‘(3) Data on enrollment. 
‘‘(4) Data on disenrollment. 
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‘‘(5) Data on the number of claims that are de-
nied. 
‘‘(6) Data on rating practices. 
‘‘(7) Information on cost-sharing and payments 
with respect to any out-of-network coverage (or with 
respect to any item and service furnished under such 
a plan or such group or individual health insurance 
coverage that does not use a network of providers). 
‘‘(8) Information on enrollee rights under this 
part. 
‘‘(9) Rate and payment information described 
in subsection (d). 
‘‘(10) Other information as determined appro-
priate by the Secretary. 
Rate and payment information described in paragraph (9) 
shall be made available to the public not later than Janu-
ary 10, 2025, and not later than the tenth day of every 
month thereafter, in the manner described in subsection 
(d)(2)(A), and, beginning on January 1, 2027, in real-time 
through an application program interface (or successor 
technology) described in subsection (d)(2)(B). 
‘‘(b) USE OF PLAIN LANGUAGE.—The information 
required to be submitted under subsection (a) shall be pro-
vided in plain language. The term ‘plain language’ means 
language that the intended audience, including individuals 
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with limited English proficiency, can readily understand 
and use because that language is clear, concise, well-orga-
nized, accurately describes the information, and follows 
other best practices of plain language writing. The Sec-
retary, jointly with the Secretary of Labor and the Sec-
retary of the Treasury, shall develop and issue standards 
for plain language writing for purposes of this section and 
shall develop a standardized reporting template and stand-
ardized definitions of terms to allow for comparison across 
group health plans and health insurance coverage. 
‘‘(c) COST SHARING TRANSPARENCY.— 
‘‘(1) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group or individual 
health insurance coverage, shall, upon request of an 
enrollee and in a timely manner, provide to the en-
rollee a statement of the amount of cost-sharing (in-
cluding deductibles, copayments, and coinsurance) 
under the enrollee’s plan or coverage that the en-
rollee would be responsible for paying with respect 
to the furnishing of a specific item or service by a 
provider. At a minimum, such information shall in-
clude the information specified in paragraph (2) and 
shall be made available at no cost to the enrollee 
through a self-service tool that meets the require-
ments of paragraph (3) or through a paper or phone 
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disclosure, at the option of the enrollee, that meets 
such requirements as the Secretary may specify. 
‘‘(2) SPECIFIED INFORMATION.—For purposes 
of paragraph (1), the information specified in this 
paragraph is, with respect to an item or service for 
which benefits are available under a group health 
plan or group or individual health insurance cov-
erage (as applicable) furnished by a health care pro-
vider to an enrollee of such plan or coverage, the fol-
lowing: 
‘‘(A) If such provider is a participating 
provider with respect to such item or service, 
the in-network rate (as defined in subsection 
(f)) for such item or service and for any other 
item or service that is inherent in the fur-
nishing of the item or service that is the subject 
of such request. 
‘‘(B) If such provider is not a participating 
provider, the allowed amount, percentage of 
billed charges, or other rate that such plan or 
coverage will recognize as payment for such 
item or service, along with a notice that such 
enrollee may be liable for additional charges 
billed by such provider. 
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‘‘(C) The estimated amount of cost sharing 
(including deductibles, copayments, and coin-
surance) that the enrollee will incur for such 
item or service (which, in the case such item or 
service is to be furnished by a provider de-
scribed in subparagraph (B), shall be calculated 
using the amount or rate described in such sub-
paragraph (or, in the case such plan or issuer 
uses a percentage of billed charges to deter-
mined the amount of payment for such pro-
vider, using a reasonable estimate of such per-
centage of such charges)). 
‘‘(D) The amount the enrollee has already 
accumulated with respect to any deductible or 
out of pocket maximum under the plan or cov-
erage (broken down, in the case separate 
deductibles or maximums apply to separate en-
rollees in the plan or coverage, by such separate 
deductibles or maximums, in addition to any 
cumulative deductible or maximum). 
‘‘(E) Any shared savings or other benefit 
available to the enrollee with respect to such 
item or service. 
‘‘(F) In the case such plan or coverage im-
poses any frequency or volume limitations with 
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respect to such item or service (excluding med-
ical necessity determinations), the amount that 
such enrollee has accrued towards such limita-
tion with respect to such item or service. 
‘‘(G) Any prior authorization, concurrent 
review, step therapy, fail first, or similar re-
quirements applicable to coverage of such item 
or service under such plan or group or indi-
vidual health insurance coverage. 
‘‘(3) SELF-SERVICE
TOOL.—For purposes of 
paragraph (1), a self-service tool established by a 
group health plan or health insurance issuer offering 
group or individual health insurance coverage meets 
the requirements of this paragraph if such tool— 
‘‘(A) is based on an Internet website, mo-
bile application, or other platform determined 
appropriate by the Secretary; 
‘‘(B) provides for real-time responses to re-
quests described in paragraph (1); 
‘‘(C) is updated in a manner such that in-
formation provided through such tool is accu-
rate at the time such request is made; 
‘‘(D) allows such a request to be made 
with respect to an item or service furnished 
by— 
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‘‘(i) a specific provider that is a par-
ticipating provider with respect to such 
item or service; 
‘‘(ii) all providers that are partici-
pating providers with respect to such plan 
and such item or service for purposes of 
facilitating price comparisons; or 
‘‘(iii) a provider that is not described 
in clause (ii); and 
‘‘(E) provides that such a request may be 
made with respect to an item or service through 
use of the billing code for such item or service 
or through use of a descriptive term for such 
item or service. 
The Secretary may require such tool, as a condition 
of complying with subparagraph (E), to link multiple 
billing codes to a single descriptive term if the Sec-
retary determines that the billing codes to be so 
linked correspond to items and services. 
‘‘(4) PROVIDER TOOL.—A group health plan, 
and a health insurance issuer offering group or indi-
vidual health insurance coverage, shall permit pro-
viders to learn the amount of cost-sharing (including 
deductibles, copayments, and coinsurance) that 
would apply under an individual’s plan or coverage 
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that the individual would be responsible for paying 
with respect to the furnishing of a specific item or 
service by another provider in a timely manner upon 
the request of the provider and with the consent of 
such individual in the same manner and to the same 
extent as if such request has been made by such in-
dividual. As part of any tool used to facilitate such 
requests from a provider, such plan or issuer offer-
ing 
health 
insurance 
coverage 
may 
include 
functionality that— 
‘‘(A) allows providers to submit the notifi-
cations to such plan or coverage required under 
section 2799B–6; and 
‘‘(B) provides for notifications required 
under section 2799A–1(f) to such an individual. 
‘‘(d) RATE AND PAYMENT INFORMATION.— 
‘‘(1) IN GENERAL.—For purposes of subsection 
(a)(9), the rate and payment information described 
in this subsection is, with respect to a group health 
plan or group or individual health insurance cov-
erage (as applicable), the following: 
‘‘(A) With respect to each item or service 
(other than a drug) for which benefits are avail-
able under such plan or coverage, the in-net-
work rate (in a dollar amount) in effect as of 
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the first day of the plan year during which such 
information is submitted with each provider 
(identified by national provider identifier) that 
is a participating provider with respect to such 
item or service (or, in the case such rate is not 
available in a dollar amount, such formulae, 
pricing methodologies, or other information 
used to calculate such rate). 
‘‘(B) With respect to each dosage form and 
indication of each drug (identified by national 
drug code) for which benefits are available 
under such plan or coverage— 
‘‘(i) the in-network rate (in a dollar 
amount) in effect as of the first day of the 
plan year during which such information is 
submitted with each provider (identified by 
national provider identifier) that is a par-
ticipating provider with respect to such 
drug (or, in the case such rate is not avail-
able in a dollar amount, such formulae, 
pricing methodologies, or other information 
used to calculate such rate); and 
‘‘(ii) the average amount paid by such 
plan (net of rebates, discounts, and price 
concessions) for such drug dispensed or 
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administered during the 90-day period be-
ginning 180 days before such date of sub-
mission to each provider that was a par-
ticipating provider with respect to such 
drug, broken down by each such provider 
(identified by national provider identifier), 
other than such an amount paid to a pro-
vider that, during such period, submitted 
fewer than 20 claims for such drug to such 
plan or coverage. 
‘‘(C) With respect to each item or service 
for which benefits are available under such plan 
or coverage, the amount billed, and the amount 
allowed by the plan or coverage, for each such 
item or service furnished during the 90-day pe-
riod specified in subparagraph (B) by a pro-
vider that was not a participating provider with 
respect to such item or service, broken down by 
each such provider (identified by national pro-
vider identifier), other than items and services 
with respect to which fewer than 20 claims for 
such item or service were submitted to such 
plan or coverage during such period. 
Such rate and payment information shall be made 
available with respect to each individual item or 
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service, regardless of whether such item or service is 
paid for as part of a bundled payment, episode of 
care, value-based payment arrangement, or other-
wise. 
‘‘(2) MANNER OF PUBLICATION.— 
‘‘(A) IN GENERAL.—Rate and payment in-
formation required to be made available under 
subsection (a)(9) shall be so made available in 
dollar amounts through 3 separate machine- 
readable files corresponding to the information 
described in each of subparagraphs (A) through 
(C) of paragraph (1) that meet such require-
ments as specified by the Secretary not later 
than 180 days after the date of the enactment 
of this paragraph through rulemaking. Such re-
quirements shall ensure that such files are lim-
ited to an appropriate size, do not include infor-
mation that is duplicative of information con-
tained in other files made available under such 
subsection, are made available in a widely-avail-
able format that allows for information con-
tained in such files to be compared across 
group health plans and group or individual 
health insurance coverage, and are accessible to 
individuals at no cost and without the need to 
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establish a user account or provide other cre-
dentials. 
‘‘(B) REAL-TIME PROVISION OF INFORMA-
TION.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), beginning January 1, 2026, rate and 
payment information required to be made 
available by a group health plan or health 
insurance issuer under subsection (a)(9) 
shall, in addition to being made available 
in the manner described in subparagraph 
(A), be made available through an applica-
tion program interface (or successor tech-
nology) that provides access to such infor-
mation in real time and that meets such 
technical standards as may be specified by 
the Secretary. 
‘‘(ii) EXEMPTION FOR CERTAIN PLANS 
AND
COVERAGE.—Clause (i) shall not 
apply with respect to information described 
in such clause required to be made avail-
able by a group health plan or health in-
surance issuer offering health insurance 
coverage if such plan or coverage, as appli-
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cable, provides benefits for fewer than 500 
enrollees. 
‘‘(3) USER GUIDE.—The Secretary, Secretary 
of Labor, and Secretary of the Treasury shall jointly 
make available to the public instructions written in 
plain language explaining how individuals may 
search for information described in paragraph (1) in 
files submitted in accordance with paragraph (2). 
‘‘(4) ANNUAL SUMMARY.—For each year (be-
ginning with 2025), each group health plan and 
health insurance issuer offering group or individual 
health insurance coverage shall make public a ma-
chine-readable file meeting such standards as estab-
lished by the Secretary under paragraph (2) con-
taining a summary of all rate and payment informa-
tion made public by such plan or issuer with respect 
to such plan or coverage during such year (such as 
averages of all such information so made public). 
‘‘(e) ATTESTATION.—Each group health plan and 
health insurance issuer offering group or individual health 
insurance coverage shall annually submit to the Secretary 
an attestation of such plan’s or such coverage’s compliance 
with the provisions of this section along with a link to dis-
closures made in accordance with subsection (a). 
‘‘(f) DEFINITIONS.—In this subsection: 
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‘‘(1) PARTICIPATING
PROVIDER.—The term 
‘participating provider’ has the meaning given such 
term in section 2799A–1 and includes a partici-
pating facility. 
‘‘(2) IN-NETWORK
RATE.—The term ‘in-net-
work rate’ means, with respect to a group health 
plan or group or individual health insurance cov-
erage and an item or service furnished by a provider 
that is a participating provider with respect to such 
plan or coverage and item or service, the contracted 
rate (reflected as a dollar amount) in effect between 
such plan or coverage and such provider for such 
item or service.’’. 
(b) REPORTS TO CONGRESS.— 
(1) QUALITY REPORT.—Not later than 1 year 
after the date of enactment of this subsection, the 
Secretary of Labor shall submit to Congress a report 
on the feasibility of including data relating to the 
quality of health care items and services with the 
price transparency information required to be made 
available under the amendments made by subsection 
(a). Such report shall include recommendations for 
legislative and regulatory actions to identify appro-
priate metrics for assessing and comparing quality 
of care. 
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(2) TRANSPARENCY
DATA
ASSESSMENT.—Not 
later than January 1, 2026, and biannually there-
after through 2032, the Secretary shall submit to 
Congress, and make publicly available on a website 
of the Department of Labor, a report with respect 
to the information described in section 719 of the 
Employee Retirement Income Security Act (29 
U.S.C. 1185h) (as amended by the ‘‘Transparency 
in Coverage Act of 2023’’), assessing the differences 
in commercial negotiated prices— 
(A) between rural and urban markets; 
(B) in the individual, small-employer, and 
large-employer markets; 
(C) in consolidated and non-consolidated 
provider markets; 
(D) between non-profit and for-profit hos-
pitals; and 
(E) between non-profit and for-profit in-
surers. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—The amendments made by 
subsection (a) shall apply to plan years beginning on 
or after January 1, 2025. 
(2) CONTINUED APPLICABILITY OF RULES FOR 
PREVIOUS
YEARS.—Nothing in the amendments 
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made by subsection (a) may be construed as affect-
ing the applicability of the rule entitled ‘‘Trans-
parency in Coverage’’ published by the Department 
of the Treasury, the Department of Labor, and the 
Department of Health and Human Services on No-
vember 12, 2020 (85 Fed. Reg. 72158) for plan 
years beginning before January 1, 2025. 
SEC. 3. PHARMACY BENEFIT MANAGER TRANSPARENCY. 
(a) 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 January 1, 2025, a group health plan (or health in-
surance issuer offering group health insurance coverage 
in connection with such a plan) or an entity or subsidiary 
providing pharmacy benefits management services on be-
half of such a plan or issuer may not enter into a contract 
with a drug manufacturer, distributor, wholesaler, switch, 
patient or copay assistance program administrator, phar-
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macy, subcontractor, rebate aggregator, or any associated 
third party that limits or delays the disclosure of informa-
tion to plan administrators 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 or substantiating the reports 
described in subsection (b). 
‘‘(b) REPORTS.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after January 1, 2025, not less frequently 
than quarterly (and upon request by the plan admin-
istrator), a group health plan or health insurance 
issuer offering group health insurance coverage, or 
an entity providing pharmacy benefits management 
services on behalf of a group health plan or an 
issuer providing group health insurance coverage, 
shall submit to the plan administrator (as defined in 
section 3(16)(A)) of such plan or coverage a report 
in accordance with this subsection, and make such 
report available to the plan administrator in a ma-
chine-readable format (or as may be determined by 
the Secretary, other formats). Each such report 
shall include, with respect to the applicable group 
health plan or health insurance coverage— 
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tion 
(as 
defined 
in 
section 
408(b)(2)(B)(ii)(dd)(AA)) to brokerage houses, 
brokers, consultants, advisors, or any other in-
dividual or firm for the referral of the group 
health plan’s or health insurance issuer’s busi-
ness to the pharmacy benefits manager, identi-
fied by the recipient of such amounts; 
‘‘(F)(i) an explanation of any benefit de-
sign parameters that encourage or require par-
ticipants and beneficiaries in the plan or cov-
erage to fill prescriptions at mail order, spe-
cialty, or retail pharmacies that are affiliated 
with or under common ownership with the enti-
ty providing pharmacy benefit management 
services under such plan or coverage, including 
mandatory mail and specialty home delivery 
programs, retail and mail auto-refill programs, 
and cost-sharing assistance incentives funded 
by an entity providing pharmacy benefit man-
agement services; 
‘‘(ii) the percentage of total prescrip-
tions charged to the plan, issuer, or par-
ticipants and beneficiaries in such plan or 
coverage, that were dispensed by mail 
order, specialty, or retail pharmacies that 
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are affiliated with or under common own-
ership with the entity providing pharmacy 
benefit management services; and 
‘‘(iii) a list of all drugs dispensed by 
such affiliated pharmacy or pharmacy 
under common ownership and charged to 
the plan, issuer, or participants and bene-
ficiaries of the plan, during the applicable 
period, and, with respect to each drug— 
‘‘(I)(aa) the amount charged, per 
dosage unit, per 30-day supply, and 
per 90-day supply, with respect to 
participants and beneficiaries in the 
plan or coverage, to the plan or 
issuer; and 
‘‘(bb) the amount charged, 
per dosage unit, per 30-day sup-
ply, and per 90-day supply, to 
participants and beneficiaries; 
‘‘(II) the median amount charged 
to the plan or issuer, per dosage unit, 
per 30-day supply, and per 90-day 
supply, including amounts paid by the 
participants and beneficiaries, when 
the same drug is dispensed by other 
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pharmacies that are not affiliated with 
or under common ownership with the 
entity and that are included in the 
pharmacy network of such plan or 
coverage; 
‘‘(III) the interquartile range of 
the costs, per dosage unit, per 30-day 
supply, and per 90-day supply, includ-
ing amounts paid by the participants 
and beneficiaries, when the same drug 
is dispensed by other pharmacies that 
are not affiliated with or under com-
mon ownership with the entity and 
that are included in the pharmacy 
network of that plan or coverage; 
‘‘(IV) the lowest cost, per dosage 
unit, per 30-day supply, and per 90- 
day supply, for such drug, including 
amounts charged to the plan and par-
ticipants and beneficiaries, that is 
available from any pharmacy included 
in the network of the plan or cov-
erage; 
‘‘(V) the net acquisition cost per 
dosage unit, per 30-day supply, and 
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per 90-day supply, if the drug is sub-
ject to a maximum price discount; and 
‘‘(VI) other information with re-
spect to the cost of the drug, as deter-
mined by the Secretary, such as aver-
age sales price, wholesale acquisition 
cost, and national average drug acqui-
sition cost per dosage unit or per 30- 
day supply, and per 90-day supply, 
for such drug, including amounts 
charged to the plan or issuer and par-
ticipants and beneficiaries among all 
pharmacies included in the network of 
such plan or coverage; and 
‘‘(G) in the case of a large employer— 
‘‘(i) a list of each drug covered by 
such plan, issuer, or entity providing phar-
macy benefits management services for 
which a claim was filed during the report-
ing period, including, with respect to each 
such drug during the reporting period— 
‘‘(I) the brand name, generic or 
non-proprietary name, and the Na-
tional Drug Code; 
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‘‘(II)(aa) the number of partici-
pants and beneficiaries for whom a 
claim for such drug was filed during 
the reporting period, the total number 
of prescription claims for such drug 
(including original prescriptions and 
refills), and the total number of dos-
age units and total days supply of 
such drug for which a claim was filed 
during the reporting period; and 
‘‘(bb) with respect to each 
claim or dosage unit described in 
item (aa), the type of dispensing 
channel used, such as retail, mail 
order, or specialty pharmacy; 
‘‘(III) the wholesale acquisition 
cost, listed as cost per days supply 
and cost per dosage unit on date of 
dispensing; 
‘‘(IV) 
the 
total 
out-of-pocket 
spending by participants and bene-
ficiaries on such drug after applica-
tion of any benefits under such plan 
or coverage, including participant and 
beneficiary spending through copay-
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ments, coinsurance, and deductibles 
(but not including any amounts spent 
by participants and beneficiaries on 
drugs not covered under such plan or 
coverage, or for which no claim was 
submitted to such plan or coverage); 
‘‘(V) for any drug for which 
gross spending of the plan or coverage 
exceeded $10,000 during the report-
ing period— 
‘‘(aa) a list of all other 
drugs in the same therapeutic 
category or class, including brand 
name drugs, biological products, 
generic drugs, or biosimilar bio-
logical products that are in the 
same therapeutic category or 
class as such drug; and 
‘‘(bb) the rationale for pre-
ferred formulary placement of 
such drug in that therapeutic 
category or class, if applicable; 
and 
‘‘(ii) a list of each therapeutic cat-
egory or class of drugs for which a claim 
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was filed under the health plan or health 
insurance coverage during the reporting 
period, and, with respect to each such 
therapeutic category or class of drugs dur-
ing the reporting period— 
‘‘(I) total gross spending by the 
plan; 
‘‘(II) the number of participants 
and beneficiaries who filled a prescrip-
tion for a drug in that category or 
class; 
‘‘(III) if applicable to that cat-
egory or class, a description of the 
formulary tiers and utilization mecha-
nisms (such as prior authorization or 
step therapy) employed for drugs in 
that category or class; 
‘‘(IV) 
the 
total 
out-of-pocket 
spending by participants and bene-
ficiaries, including participant and 
beneficiary spending through copay-
ments, coinsurance, and deductibles; 
and 
‘‘(V) for each drug— 
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within the therapeutic class for 
which a claim was filed during 
the reporting period. 
‘‘(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 
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 
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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 en-
tity may not restrict disclosure of such report 
to the Department of Health and Human Serv-
ices, the Department of Labor, the Department 
of the Treasury, the Comptroller 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 administrators who are drug 
manufacturers, drug wholesalers, or other direct 
participants in the drug supply chain, in order 
to prevent anti-competitive behavior. 
‘‘(4) REPORT
TO
GAO.—A health insurance 
issuer offering group health insurance coverage or 
an entity providing pharmacy benefits management 
services on behalf of a group health plan shall sub-
mit to the Comptroller General of the United States 
each of the first 4 reports submitted to a plan ad-
ministrator under paragraph (1) with respect to 
such coverage or plan, and other such reports as re-
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quested, in accordance with the privacy requirements 
under paragraph (2), the disclosure and redisclosure 
standards under paragraph (3), the standards speci-
fied pursuant to paragraph (5). 
‘‘(5) STANDARD
FORMAT.—Not later than 6 
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) 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 Department of Labor 
to a report described in subsection (b)(1) or information 
related to compliance with subsection (a) by such issuer, 
plan, or entity. 
‘‘(d) DEFINITIONS.—In this section: 
‘‘(1) LARGE EMPLOYER.—The term ‘large em-
ployer’ means, in connection with a group health 
plan with respect to a calendar year and a plan year, 
an employer who employed an average of at least 50 
employees on business days during the preceding 
calendar year and who employs at least 1 employee 
on the first day of the plan year. 
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‘‘(2) WHOLESALE
ACQUISITION
COST.—The 
term ‘wholesale 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, 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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‘‘(A) FAILURE TO PROVIDE TIMELY INFOR-
MATION.—The Secretary may impose a penalty 
against any health insurance issuer or entity 
providing pharmacy benefits management serv-
ices that violates section 726(a) or fails to pro-
vide information required under section 726(b) 
in the amount of $10,000 for each day during 
which such violation continues or such informa-
tion is not disclosed or reported. 
‘‘(B) FALSE
INFORMATION.—The Sec-
retary may impose a penalty against a health 
insurance issuer or entity providing pharmacy 
benefits management services that knowingly 
provides false information under section 726 in 
an amount not to exceed $100,000 for each 
item of false information. Such penalty shall be 
in addition to other penalties as may be pre-
scribed 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.’’. 
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(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.’’. 
(b) PHSA.—Part D of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg–111 et seq.) is 
amended by adding at the end the following new section: 
‘‘SEC. 2799A–11. OVERSIGHT OF PHARMACY BENEFITS MAN-
AGER SERVICES. 
‘‘(a) IN GENERAL.—For plan years beginning on or 
after January 1, 2025, a group health plan (or health in-
surance issuer offering group health insurance coverage 
in connection with such a plan) or an entity or subsidiary 
providing pharmacy benefits management services on be-
half of such a plan or issuer may not enter into a contract 
with a drug manufacturer, distributor, wholesaler, switch, 
patient or copay assistance program administrator, phar-
macy, subcontractor, rebate aggregator, or any associated 
third party that limits or delays the disclosure of informa-
tion to plan administrators 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 or substantiating the reports 
described in subsection (b). 
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‘‘(b) REPORTS.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after January 1, 2025, not less frequently 
than quarterly (and upon request by the plan admin-
istrator), a group health plan or health insurance 
issuer offering group health insurance coverage, or 
an entity providing pharmacy benefits management 
services on behalf of a group health plan or an 
issuer providing group health insurance coverage, 
shall submit to the plan administrator (as defined in 
section 3(16)(A) of the Employee Retirement In-
come Security Act of 1974) of such plan or coverage 
a report in accordance with this subsection, and 
make such report available to the plan administrator 
in a machine-readable format (or as may be deter-
mined by the Secretary, other formats). Each such 
report shall include, with respect to the applicable 
group health plan or health insurance coverage— 
‘‘(A) information collected from a patient 
or copay assistance program administrator by 
such entity on the total amount of copayment 
assistance dollars paid, or copayment cards ap-
plied, or other discounts that were funded by 
the drug manufacturer with respect to the par-
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ticipants and beneficiaries in such plan or cov-
erage; 
‘‘(B) total gross spending on prescription 
drugs by the plan or coverage during the re-
porting period; 
‘‘(C) total amount received, or expected to 
be received, by the plan or coverage from any 
entities, in rebates, fees, alternative discounts, 
and all other remuneration received from the 
entity or any third party (including group pur-
chasing organizations) other than the plan ad-
ministrator, related to utilization of drug or 
drug spending under such plan or coverage dur-
ing the reporting period; 
‘‘(D) the total net spending on prescription 
drugs by the plan or coverage during such re-
porting period; 
‘‘(E) amounts paid, directly or indirectly, 
in rebates, fees, or any other type of compensa-
tion 
(as 
defined 
in 
section 
408(b)(2)(B)(ii)(dd)(AA) of the Employee Re-
tirement Income Security Act of 1974) to bro-
kerage houses, brokers, consultants, advisors, or 
any other individual or firm for the referral of 
the group health plan’s or health insurance 
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issuer’s business to the pharmacy benefits man-
ager, identified by the recipient of such 
amounts; 
‘‘(F)(i) an explanation of any benefit de-
sign parameters that encourage or require par-
ticipants and beneficiaries in the plan or cov-
erage to fill prescriptions at mail order, spe-
cialty, or retail pharmacies that are affiliated 
with or under common ownership with the enti-
ty providing pharmacy benefit management 
services under such plan or coverage, including 
mandatory mail and specialty home delivery 
programs, retail and mail auto-refill programs, 
and cost-sharing assistance incentives funded 
by an entity providing pharmacy benefit man-
agement services; 
‘‘(ii) the percentage of total prescrip-
tions charged to the plan, issuer, or par-
ticipants and beneficiaries in such plan or 
coverage, that were dispensed by mail 
order, specialty, or retail pharmacies that 
are affiliated with or under common own-
ership with the entity providing pharmacy 
benefit management services; and 
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‘‘(iii) a list of all drugs dispensed by 
such affiliated pharmacy or pharmacy 
under common ownership and charged to 
the plan, issuer, or participants and bene-
ficiaries of the plan, during the applicable 
period, and, with respect to each drug— 
‘‘(I)(aa) the amount charged, per 
dosage unit, per 30-day supply, and 
per 90-day supply, with respect to 
participants and beneficiaries in the 
plan or coverage, to the plan or 
issuer; and 
‘‘(bb) the amount charged, 
per dosage unit, per 30-day sup-
ply, and per 90-day supply, to 
participants and beneficiaries; 
‘‘(II) the median amount charged 
to the plan or issuer, per dosage unit, 
per 30-day supply, and per 90-day 
supply, including amounts paid by the 
participants and beneficiaries, when 
the same drug is dispensed by other 
pharmacies that are not affiliated with 
or under common ownership with the 
entity and that are included in the 
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pharmacy network of such plan or 
coverage; 
‘‘(III) the interquartile range of 
the costs, per dosage unit, per 30-day 
supply, and per 90-day supply, includ-
ing amounts paid by the participants 
and beneficiaries, when the same drug 
is dispensed by other pharmacies that 
are not affiliated with or under com-
mon ownership with the entity and 
that are included in the pharmacy 
network of that plan or coverage; 
‘‘(IV) the lowest cost, per dosage 
unit, per 30-day supply, and per 90- 
day supply, for such drug, including 
amounts charged to the plan and par-
ticipants and beneficiaries, that is 
available from any pharmacy included 
in the network of the plan or cov-
erage; 
‘‘(V) the net acquisition cost per 
dosage unit, per 30-day supply, and 
per 90-day supply, if the drug is sub-
ject to a maximum price discount; and 
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‘‘(VI) other information with re-
spect to the cost of the drug, as deter-
mined by the Secretary, such as aver-
age sales price, wholesale acquisition 
cost, and national average drug acqui-
sition cost per dosage unit or per 30- 
day supply, and per 90-day supply, 
for such drug, including amounts 
charged to the plan or issuer and par-
ticipants and beneficiaries among all 
pharmacies included in the network of 
such plan or coverage; and 
‘‘(G) in the case of a large employer— 
‘‘(i) a list of each drug covered by 
such plan, issuer, or entity providing phar-
macy benefits management services for 
which a claim was filed during the report-
ing period, including, with respect to each 
such drug during the reporting period— 
‘‘(I) the brand name, generic or 
non-proprietary name, and the Na-
tional Drug Code; 
‘‘(II)(aa) the number of partici-
pants and beneficiaries for whom a 
claim for such drug was filed during 
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the reporting period, the total number 
of prescription claims for such drug 
(including original prescriptions and 
refills), and the total number of dos-
age units and total days supply of 
such drug for which a claim was filed 
during the reporting period; and 
‘‘(bb) with respect to each 
claim or dosage unit described in 
item (aa), the type of dispensing 
channel used, such as retail, mail 
order, or specialty pharmacy; 
‘‘(III) the wholesale acquisition 
cost, listed as cost per days supply 
and cost per dosage unit on date of 
dispensing; 
‘‘(IV) 
the 
total 
out-of-pocket 
spending by participants and bene-
ficiaries on such drug after applica-
tion of any benefits under such plan 
or coverage, including participant and 
beneficiary spending through copay-
ments, coinsurance, and deductibles 
(but not including any amounts spent 
by participants and beneficiaries on 
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drugs not covered under such plan or 
coverage, or for which no claim was 
submitted to such plan or coverage); 
‘‘(V) for any drug for which 
gross spending of the plan or coverage 
exceeded $10,000 during the report-
ing period— 
‘‘(aa) a list of all other 
drugs in the same therapeutic 
category or class, including brand 
name drugs, biological products, 
generic drugs, or biosimilar bio-
logical products that are in the 
same therapeutic category or 
class as such drug; and 
‘‘(bb) the rationale for pre-
ferred formulary placement of 
such drug in that therapeutic 
category or class, if applicable; 
and 
‘‘(ii) a list of each therapeutic cat-
egory or class of drugs for which a claim 
was filed under the health plan or health 
insurance coverage during the reporting 
period, and, with respect to each such 
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therapeutic category or class of drugs dur-
ing the reporting period— 
‘‘(I) total gross spending by the 
plan; 
‘‘(II) the number of participants 
and beneficiaries who filled a prescrip-
tion for a drug in that category or 
class; 
‘‘(III) if applicable to that cat-
egory or class, a description of the 
formulary tiers and utilization mecha-
nisms (such as prior authorization or 
step therapy) employed for drugs in 
that category or class; 
‘‘(IV) 
the 
total 
out-of-pocket 
spending by participants and bene-
ficiaries, including participant and 
beneficiary spending through copay-
ments, coinsurance, and deductibles; 
and 
‘‘(V) for each drug— 
‘‘(aa) the amount received, 
or expected to be received, from 
any entity in rebates, fees, alter-
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native discounts, or other remu-
neration— 
‘‘(AA) for claims in-
curred during the reporting 
period; or 
‘‘(BB) that is related to 
utilization of drugs or drug 
spending; 
‘‘(bb) the total net spending, 
after deducting rebates, price 
concessions, alternative discounts 
or other remuneration from drug 
manufacturers, by the health 
plan or health insurance coverage 
on that category or class of 
drugs; and 
‘‘(cc) the average net spend-
ing per 30-day supply and per 
90-day supply, incurred by the 
health plan or health insurance 
coverage and its participants and 
beneficiaries, among all drugs 
within the therapeutic class for 
which a claim was filed during 
the reporting period. 
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‘‘(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 
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-
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‘‘(IV) 
the 
total 
out-of-pocket 
spending by participants and bene-
ficiaries, including participant and 
beneficiary spending through copay-
ments, coinsurance, and deductibles; 
and 
‘‘(V) for each drug— 
‘‘(aa) the amount received, 
or expected to be received, from 
any entity in rebates, fees, alter-
native discounts, or other remu-
neration— 
‘‘(AA) for claims in-
curred during the reporting 
period; or 
‘‘(BB) that is related to 
utilization of drugs or drug 
spending; 
‘‘(bb) the total net spending, 
after deducting rebates, price 
concessions, alternative discounts 
or other remuneration from drug 
manufacturers, by the plan on 
that category or class of drugs; 
and 
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