used under this section, by dividing the 
units determined under clause (i) for each 
National Drug Code of such drug by the 
billing unit for the billing and payment 
code of such drug. 
‘‘(iii) Compute the sum of the billing 
units for each National Drug Code of such 
drug in clause (ii).’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to cal-
endar quarters beginning after the date of the enact-
ment of this Act. 
(b) COVERED PART D DRUGS.— 
(1) APPLICATION OF PRESCRIPTION DRUG IN-
FLATION REBATES TO DRUGS FURNISHED IN THE 
COMMERCIAL MARKET.—Section 1860D–14B of the 
Social Security Act (42 U.S.C. 1395w–114b) is 
amended— 
(A) in subsection (b)— 
(i) in paragraph (1)— 
(I) in subparagraph (A)(i), by 
striking ‘‘the total number of units’’ 
and all that follows through the semi-
colon and inserting the following: ‘‘the 
total number of units that are used to 
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calculate the average manufacturer 
price of such dosage form and 
strength with respect to such part D 
rebatable drug, as reported by the 
manufacturer of such drug under sec-
tion 1927 for each month, with re-
spect to such period;’’; and 
(II) by striking subparagraph (B) 
and inserting the following: 
‘‘(B) EXCLUDED UNITS.—For purposes of 
subparagraph (A)(i), the Secretary shall exclude 
from the total number of units for a dosage 
form and strength with respect to a part D 
rebatable drug, with respect to an applicable pe-
riod, the following: 
‘‘(i) Units of each dosage form and 
strength of such part D rebatable drug for 
which payment was made under a State 
plan under title XIX (or waiver of such 
plan), as reported by States under section 
1927(b)(2)(A). 
‘‘(ii) Units of each dosage form and 
strength of such part D rebatable drug for 
which a rebate is paid under section 
1847A(i). 
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‘‘(iii) Beginning with plan year 2026, 
units of each dosage form and strength of 
such part D rebatable drug for which the 
manufacturer provides a discount under 
the program under section 340B of the 
Public Health Service Act.’’; and 
(ii) in paragraph (6), by striking ‘‘IN-
FORMATION’’ and all that follows through 
‘‘rebatable covered part D drug dispensed’’ 
and inserting the following: ‘‘AMP RE-
PORTS.—The Secretary shall provide for a 
method and process under which, in the 
case of a manufacturer of a part D 
rebatable drug that submits revisions to in-
formation submitted under section 1927 by 
the manufacturer with respect to such 
drug’’; and 
(B) by striking subsection (d) and insert-
ing the following: 
‘‘(d) INFORMATION.—For purposes of carrying out 
this section, the Secretary shall use information submitted 
by manufacturers under section 1927(b)(3) and informa-
tion submitted by States under section 1927(b)(2)(A).’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to appli-
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cable periods (as defined in section 1860D– 
14B(g)(7) of the Social Security Act (42 U.S.C. 
1395w–114b(g)(7))) beginning after the date of the 
enactment of this Act. 
TITLE III—OUT-OF-POCKET LIM-
ITS 
FOR 
PRESCRIPTION 
DRUGS 
SEC. 301. ESTABLISHING AN OUT-OF-POCKET LIMIT ON EX-
PENDITURES 
FOR 
PRESCRIPTION 
DRUGS 
UNDER GROUP HEALTH PLANS AND GROUP 
AND INDIVIDUAL HEALTH INSURANCE COV-
ERAGE. 
(a) PHSA.—Title XXVII of the Public Health Serv-
ice Act (42 U.S.C. 300gg et seq.), as amended by section 
101, is further amended— 
(1) in section 2707, by adding at the end the 
following new subsection: 
‘‘(e) SUNSET.—The preceding provisions of this sec-
tion shall not apply with respect to plan years beginning 
on or after January 1, 2027.’’; and 
(2) in part D, by adding at the end the fol-
lowing new section: 
‘‘SEC. 2799A–12. COMPREHENSIVE COVERAGE. 
‘‘(a) COVERAGE FOR ESSENTIAL HEALTH BENEFITS 
PACKAGE.—A health insurance issuer that offers health 
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insurance coverage in the individual or small group market 
shall ensure that such coverage includes the essential 
health benefits package required under section 1302(a) of 
the Patient Protection and Affordable Care Act. 
‘‘(b) COST-SHARING LIMITATION.— 
‘‘(1) IN GENERAL.—A group health plan and a 
health insurance issuer offering group or individual 
health insurance coverage shall ensure that— 
‘‘(A) any annual cost-sharing imposed 
under the plan or coverage (including any such 
cost-sharing so imposed with respect to pre-
scription drugs) does not exceed the dollar 
amounts specified in paragraph (2); and 
‘‘(B) any annual cost-sharing imposed 
under the plan or coverage with respect to pre-
scription drugs does not exceed the dollar 
amounts specified in paragraph (3). 
‘‘(2) LIMITATION ON OVERALL OUT-OF-POCKET 
COST-SHARING.—For purposes of paragraph (1)(A), 
the dollar amounts specified in this paragraph are 
the following: 
‘‘(A) With respect to self-only coverage— 
‘‘(i) for plan years beginning in 2027, 
the dollar amount in effect under section 
1302(c)(1) of the Patient Protection and 
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Affordable Care Act for such coverage for 
plan years beginning in 2014, increased by 
an amount equal to the product of that 
amount and the premium adjustment per-
centage specified in paragraph (4) of such 
section for the calendar year; and 
‘‘(ii) for plan years beginning in 2028 
or a subsequent year, the dollar amount in 
effect under this subparagraph for plan 
years beginning in 2027, increased by an 
amount equal to the product of that 
amount the premium adjustment percent-
age specified in paragraph (4) for the cal-
endar year. 
‘‘(B) With respect to coverage other than 
self-only coverage, for plan years beginning in 
2027 or a subsequent year, twice the amount in 
effect under subparagraph (A) for such plan 
year. 
If the amount of any increase under subparagraph 
(A) is not a multiple of $50, such increase shall be 
rounded to the next lowest multiple of $50. 
‘‘(3) LIMITATION ON PRESCRIPTION DRUG OUT- 
OF-POCKET COST-SHARING.—For purposes of para-
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graph (1)(B), the dollar amounts specified in this 
paragraph are the following: 
‘‘(A) With respect to self-only coverage— 
‘‘(i) for plan years beginning in 2027, 
$2,000; and 
‘‘(ii) for plan years beginning in 2028 
or a subsequent year, the dollar amount in 
effect under this subparagraph for plan 
years beginning in 2027, increased by an 
amount equal to the product of that 
amount and the premium adjustment per-
centage under paragraph (4) for the cal-
endar year. 
‘‘(B) With respect to coverage other than 
self-only coverage, for plan years beginning in 
2027 or a subsequent year, twice the amount in 
effect under subparagraph (A) for such plan 
year. 
If the amount of any increase under subparagraph 
(A) is not a multiple of $50, such increase shall be 
rounded to the next lowest multiple of $50. 
‘‘(4) PREMIUM
ADJUSTMENT
PERCENTAGE.— 
For purposes of paragraphs (2)(A)(ii) and (3)(A)(ii), 
the premium adjustment percentage for any cal-
endar year is the percentage (if any) by which the 
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average per capita premium for health insurance 
coverage in the United States for the preceding cal-
endar year (as estimated by the Secretary no later 
than October 1 of such preceding calendar year) ex-
ceeds such average per capita premium for 2026 (as 
determined by the Secretary). 
‘‘(5) COST-SHARING.—In this section: 
‘‘(A) IN GENERAL.—The term ‘cost-shar-
ing’ includes— 
‘‘(i) deductibles, coinsurance, copay-
ments, or similar charges; and 
‘‘(ii) any other expenditure required of 
an insured individual which is a qualified 
medical expense (within the meaning of 
section 223(d)(2) of the Internal Revenue 
Code of 1986) with respect to essential 
health benefits covered under the plan or 
coverage. 
‘‘(B) EXCEPTIONS.—Such term does not 
include premiums, balance billing amounts for 
non-network providers, or spending for non-cov-
ered services. 
‘‘(6) IMPLEMENTATION.—The Secretary may 
implement the provisions of this subsection by sub-
regulatory guidance, interim final rule, or otherwise. 
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‘‘(c) CHILD-ONLY PLANS.—If a health insurance 
issuer offers health insurance coverage in any level of cov-
erage specified under section 1302(d) of the Patient Pro-
tection and Affordable Care Act, the issuer shall also offer 
such coverage in that level as a plan in which the only 
enrollees are individuals who, as of the beginning of a plan 
year, have not attained the age of 21. 
‘‘(d) DENTAL ONLY.—This section shall not apply to 
a plan described in section 1311(d)(2)(B)(ii) of the Pa-
tient Protection and Affordable Care Act.’’. 
(b) ERISA.— 
(1) IN GENERAL.—Subpart B of part 7 of sub-
title B of title I of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1185 et seq.), as 
amended by section 101, is further amended by add-
ing at the end the following new section: 
‘‘SEC. 727. COMPREHENSIVE COVERAGE. 
‘‘(a) COVERAGE FOR ESSENTIAL HEALTH BENEFITS 
PACKAGE.—A health insurance issuer that offers health 
insurance coverage in the small group market shall ensure 
that such coverage includes the essential health benefits 
package required under section 1302(a) of the Patient 
Protection and Affordable Care Act. 
‘‘(b) COST-SHARING LIMITATION.— 
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‘‘(1) IN GENERAL.—A group health plan and a 
health insurance issuer offering group health insur-
ance coverage shall ensure that— 
‘‘(A) any annual cost-sharing imposed 
under the plan or coverage (including any such 
cost-sharing so imposed with respect to pre-
scription drugs) does not exceed the dollar 
amounts specified in paragraph (2); and 
‘‘(B) any annual cost-sharing imposed 
under the plan or coverage with respect to pre-
scription drugs does not exceed the dollar 
amounts specified in paragraph (3). 
‘‘(2) LIMITATION ON OVERALL OUT-OF-POCKET 
COST-SHARING.—For purposes of paragraph (1)(A), 
the dollar amounts specified in this paragraph are 
the following: 
‘‘(A) With respect to self-only coverage— 
‘‘(i) for plan years beginning in 2027, 
the dollar amount in effect under section 
1302(c)(1) of the Patient Protection and 
Affordable Care Act for such coverage for 
plan years beginning in 2014, increased by 
an amount equal to the product of that 
amount and the premium adjustment per-
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centage specified in paragraph (4) of such 
section for the calendar year; and 
‘‘(ii) for plan years beginning in 2028 
or a subsequent year, the dollar amount in 
effect under this subparagraph for plan 
years beginning in 2027, increased by an 
amount equal to the product of that 
amount the premium adjustment percent-
age specified in paragraph (4) for the cal-
endar year. 
‘‘(B) With respect to coverage other than 
self-only coverage, for plan years beginning in 
2027 or a subsequent year, twice the amount in 
effect under subparagraph (A) for such plan 
year. 
If the amount of any increase under subparagraph 
(A) is not a multiple of $50, such increase shall be 
rounded to the next lowest multiple of $50. 
‘‘(3) LIMITATION ON PRESCRIPTION DRUG OUT- 
OF-POCKET COST-SHARING.—For purposes of para-
graph (1)(B), the dollar amounts specified in this 
paragraph are the following: 
‘‘(A) With respect to self-only coverage— 
‘‘(i) for plan years beginning in 2027, 
$2,000; and 
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‘‘(ii) for plan years beginning in 2028 
or a subsequent year, the dollar amount in 
effect under this subparagraph for plan 
years beginning in 2027, increased by an 
amount equal to the product of that 
amount and the premium adjustment per-
centage under paragraph (4) for the cal-
endar year. 
‘‘(B) With respect to coverage other than 
self-only coverage, for plan years beginning in 
2027 or a subsequent year, twice the amount in 
effect under subparagraph (A) for such plan 
year. 
If the amount of any increase under subparagraph 
(A) is not a multiple of $50, such increase shall be 
rounded to the next lowest multiple of $50. 
‘‘(4) PREMIUM
ADJUSTMENT
PERCENTAGE.— 
For purposes of paragraphs (2)(A)(ii) and (3)(A)(ii), 
the premium adjustment percentage for any cal-
endar year is the percentage (if any) by which the 
average per capita premium for health insurance 
coverage in the United States for the preceding cal-
endar year (as estimated by the Secretary no later 
than October 1 of such preceding calendar year) ex-
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ceeds such average per capita premium for 2026 (as 
determined by the Secretary). 
‘‘(5) COST-SHARING.—In this section: 
‘‘(A) IN GENERAL.—The term ‘cost-shar-
ing’ includes— 
‘‘(i) deductibles, coinsurance, copay-
ments, or similar charges; and 
‘‘(ii) any other expenditure required of 
an insured individual which is a qualified 
medical expense (within the meaning of 
section 223(d)(2) of the Internal Revenue 
Code of 1986) with respect to essential 
health benefits covered under the plan or 
coverage. 
‘‘(B) EXCEPTIONS.—Such term does not 
include premiums, balance billing amounts for 
non-network providers, or spending for non-cov-
ered services. 
‘‘(6) IMPLEMENTATION.—The Secretary may 
implement the provisions of this subsection by sub-
regulatory guidance, interim final rule, or otherwise. 
‘‘(c) CHILD-ONLY PLANS.—If a health insurance 
issuer offers health insurance coverage in any level of cov-
erage specified under section 1302(d) of the Patient Pro-
tection and Affordable Care Act, the issuer shall also offer 
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