HR 6610
Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]
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Bill overview
```json { "summary": "This bill, the \"Pharmacists Fight Back \[in Federal Employee Health Benefit Plans Act],” aims to limit the costs associated with pharmacy benefit managers (PBMs) that administer prescription drug benefits for federal employee health plans. It mandates that PBMs reimburse in-network pharmacies for the actual cost of prescription drugs (ingredient cost plus a small percentage or fixed amount), pay professional dispensing fees aligned with state rates, and apply manufacturer rebates to reduce patient out-of-pocket costs. The bill also prohibits PBMs from directing patients to specific pharmacies, engaging in practices that favor their own affiliated pharmacies, or manipulating drug distribution to limit access for patients. Finally, it establishes penalties for non-co
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119th CONGRESS — 1st Session
H. R. 6610
IN THE HOUSE OF REPRESENTATIVES
A BILL
To amend chapter 89 of title 5, United States Code, to limit the costs of pharmacy benefit managers with respect to Federal employee health benefit plans, and for other purposes.
This Act may be cited as the Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]
.
The Office of Personnel Management may not contract for or approve a health benefits plan under section 8903 of this title unless such plan—
reimburse an in-network pharmacy for the ingredient cost of a prescription drug in an amount equal to the sum of—
remit to the carrier for such health benefits plan an amount equal to the amount of such rebate, less the amount by which the coinsurance or copayment owed by such individual with respect to such drug was reduced under subclause (I);
prohibits such pharmacy benefits manager and any affiliate thereof from—
prohibits any such pharmacy benefits manager from lowering, imposing a fee on, or otherwise make any adjustment to a prescription drug claim at the time the claim for such drug is adjudicated or after the claim is adjudicated that reduces the amount a pharmacy is reimbursed for such drug pursuant to subparagraph (A), including by charging any fee to such pharmacy that is not associated with a prescription drug claim; and
requires the carrier providing such health benefits plan to cooperate with any inspection of such carrier carried out under section 8902b(a)(3)(B) of this title, including by making available to the Office such documents, personnel, and facilities of the carrier as and when determined necessary to Office to carry out such inspection.
In this subsection:
means the managing or administration of a plan or program that pays for, reimburses, and covers the cost of prescription drugs and medical devices; and
includes the processing and payment of claims for prescription drugs and the adjudication of appeals or grievances related to the prescription drug benefit.
on such pharmacy benefits manager; and
Not later than 60 days after the date on which a carrier submits plan under subparagraph (A), and with such frequency thereafter as determined appropriate by the Office of Personnel Management, the Office of Personnel Management shall inspect such carrier to assess the compliance of such carrier with such plan.
For the purposes of this subsection, any civil monetary penalties concurrently imposed under paragraph (1) shall be deemed to be imposed sequentially.
Amounts recovered under this subsection shall be paid to the Office of Personnel Management for deposit into the Employees Health Benefits Fund.
The amount of a civil monetary penalty imposed under this subsection may be deducted from any sum then or later owing by the United States to the party against whom the penalty or assessment has been levied.
The Office of Personnel Management may not initiate any action to impose a civil monetary penalty on a pharmacy benefits manager or carrier under this subsection later than 6 years after the date of the violation of the requirement or prohibition by the pharmacy benefits manager for which such civil monetary penalty would be imposed.
Notwithstanding section 8902(j) or any other provision of this chapter, if, under this section a pharmacy benefits manager is debarred under paragraph (1), no payment may be made by a carrier pursuant to any contract under this chapter (either to such pharmacy benefits manager or by reimbursement) for any service or supply furnished by such pharmacy benefits manager during the period of the debarment.
has not been appealed and for which the period of appeal has elapsed; or
has been appealed, all appeals have been exhausted, and has not be overturned or wholly set aside.
The Office of Personnel Management shall grant a request for a hearing under paragraph (2) upon a showing that due process rights have not previously been afforded with respect to any finding of fact which is relied upon as a cause for an adverse determination under this section. Such hearing shall be conducted without regard to subchapter II of chapter 5 and chapter 7 of this title by a hearing officer who shall be designated by the Director of the Office of Personnel Management and who shall not otherwise have been involved in the adverse determination being appealed.
A request for a hearing under paragraph (2) shall be filed within such period and in accordance with such procedures as the Office of Personnel Management shall prescribe by regulation.
With respect to an appeal filed under subparagraph (A), the court shall have power to enter, upon the pleadings and evidence of record, a judgment affirming, modifying, or setting aside, in whole or in part, the final decision of the Office of Personnel Management that is the subject of such appeal, with or without remanding the case for a rehearing. The court shall not set aside or remand such final decision unless there is not substantial evidence on the record, taken as whole, to support the such final decision or unless the actions of the Office of Personnel Management with respect to such final decision constitutes an abuse of discretion.
In this section, the terms affiliate, pharmacy benefits manager and prescription drug have the meanings given such terms, respectively, in section 8904(c) of this title.
The table of sections for chapter 89 of title 5, United States Code, is amended by inserting after the item relating to section 8902a the following new item:
Section 8903a(b) of title 5, United States Code, is amended—
in paragraph (3), by striking and
at the end;
in paragraph (4), by striking the period at the end and inserting ; and
; and
by adding at the end the following new paragraph:
The amendments made by this Act shall take effect on the date that is one year after the date of the enactment of this Act.