Ensuring Seniors Access to Local Pharmacies Act of 2021
Bill: H.R.2608 | Sponsor: Rep. Welch, Peter (D-VT)
Policy area: Health

Summary:
Ensuring Seniors Access to Local Pharmacies Act of 2021
This bill establishes several requirements for prescription drug plans under the Medicare prescription drug benefit.
Specifically, the bill requires prescription drug plans to allow any pharmacy located in a health professional shortage area, a medically underserved area, or a rural area to be included as an in-network pharmacy if the plan already has other in-network pharmacies in the same area.
The bill also establishes certain standards for prescription drug plans regarding pharmacy reimbursements and related disclosures. Among other things, the bill prohibits prescription drug plans from reimbursing a pharmacy in an amount that is less than the amount the pharmacy benefits manager (PBM) reimburses an affiliated pharmacy (i.e., a pharmacy that has a shared ownership interest with the PBM) for the same services.

To amend title XVIII of the Social Security Act to ensure equal access 
of Medicare beneficiaries to community pharmacies in underserved areas 
 as network pharmacies under Medicare prescription drug coverage, and 
                          for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Ensuring Seniors Access to Local 
Pharmacies Act of 2021''.

SEC. 2. ALLOWING ANY STATE LICENSED PHARMACY SERVING AN UNDERSERVED 
              AREA TO BECOME A NETWORK PHARMACY UNDER MEDICARE 
              PRESCRIPTION DRUG COVERAGE.

    (a) In General.--Section 1860D-4(b)(1)(B) of the Social Security 
Act (42 U.S.C. 1395w-104(b)(1)(B)) is amended--
            (1) by striking ``Discounts allowed for network 
        pharmacies.--For'' and inserting the following: ``Discounts 
        allowed for network pharmacies.--
                            ``(i) In general.--For''; and
            (2) by adding at the end the following new clause:
                            ``(ii) Inclusion of pharmacies located in 
                        underserved areas in networks.--For plan years 
                        beginning on or after January 1, 2022, in the 
                        case of a prescription drug plan that has, in 
                        its network of pharmacies, one or more 
                        pharmacies located in a health professional 
                        shortage area (as defined in section 
                        332(a)(1)(A) of the Public Health Service Act), 
                        in a medically underserved area (according to a 
                        designation under section 330(b)(3)(A) of the 
                        Public Health Service Act), among a medically 
                        underserved population (as defined in such 
                        section 330(b)(3)(A) of such Act), or in a 
                        rural area (as defined by the Federal Office of 
                        Rural Health Policy), and that provides a 
                        reduction in coinsurance or copayments 
                        described in clause (i) for covered part D 
                        drugs dispensed through such pharmacies, such 
                        plan shall extend to any pharmacy located in 
                        such area or among such population the option 
                        to be an in-network pharmacy with respect to 
                        such plan under terms and conditions (including 
                        the reductions described in clause (i)) 
                        comparable to those the plan has agreed upon 
                        with other in-network pharmacies located in 
                        such area or among such population.''.

SEC. 3. REASONABLE REIMBURSEMENT REQUIREMENTS.

    Section 1860D-2(d)(1)(B) of the Social Security Act (42 U.S.C. 
1395w-102(d)(1)(B)) is amended--
            (1) by striking ``Prices.--For purposes'' and inserting 
        ``Prices.--
                            ``(i) In general.--For purposes''; and
            (2) by adding at the end the following new clauses:
                            ``(ii) Reasonable reimbursement.--For plan 
                        years beginning on or after January 1, 2022, a 
                        PDP sponsor and a Medicare Advantage 
                        organization shall ensure that--
                                    ``(I) each prescription drug plan 
                                or MA-PD plan offered by the sponsor or 
                                organization does not reimburse a 
                                pharmacy or pharmacist an amount less 
                                than the amount that the pharmacy 
                                benefits manager reimburses a pharmacy 
                                benefits manager affiliate (as defined 
                                in clause (iv)); and
                                    ``(II) in no case may the 
                                negotiated price for a covered part D 
                                drug furnished by a pharmacy under a 
                                prescription drug plan or MA-PD plan 
                                offered by the sponsor or organization, 
                                be less than such pharmacy's cost of 
                                purchasing and dispensing such drug and 
                                providing such other services 
                                associated with furnishing such drug as 
                                may be specified by the Secretary.
                            ``(iii) Claim reimbursement disclosure 
                        requirements.--With respect to payment made by 
                        a PDP sponsor or a Medicare Advantage 
                        organization to a pharmacy for a covered part D 
                        drug furnished by such pharmacy during a plan 
                        year beginning on or after January 1, 2022, 
                        such sponsor or organization shall promptly 
                        furnish all pricing components including the 
                        Network Reimbursement ID used to price the 
                        claim, any fees, pharmacy price concessions, 
                        discounts, subsidies, rebates, incentives, or 
                        any other forms of direct or indirect 
                        remuneration that affect payment and pricing of 
                        the claim as part of the claim adjudication 
                        response at the point-of sale. All pricing 
                        components described in the preceding sentence 
                        shall each be identified in a predetermined 
                        line item in the remittance advice that is 
                        standard across the industry. The PDP sponsor 
                        or Medicare Advantage organization shall 
                        include suitable claim-level detail on the 
                        electronic remittance advice that accompanies 
                        each payment. This claim-level detail shall 
                        include, in an industry standardized format, 
                        all fields needed to properly identify the 
                        claim, including the Claim Authorization 
                        Number, date of service, date of payment 
                        remittance, ingredient cost reimbursed, 
                        dispensing fee reimbursed, payment amounts 
                        including the Network ID used to price the 
                        claim, the specific dollar amounts and the 
                        appropriate qualifier codes for each payment 
                        adjustment including fees, pharmacy price 
                        concessions, or incentives.
                            ``(iv) Pharmacy benefits manager affiliate 
                        defined.--For purposes of clause (ii), the term 
                        `pharmacy benefits manager affiliate' means a 
                        pharmacy or pharmacist that directly or 
                        indirectly, through one or more intermediaries, 
                        owns or controls, is owned or controlled by, or 
                        is under common ownership or corporate control 
                        with a pharmacy benefits manager, PDP sponsor 
                        or a Medicare Advantage organization.''.
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