Sponsors (59)
Official title: To expand the drug price negotiation program under title XI of the Social Security Act and repeal certain changes to the program made by Public Law 119-21, to apply prescription drug inflation rebates under the Medicare program to drugs furnished in the commercial market, and to establish out-of-pocket limits on expenditures for prescription drugs under private health insurance.
Introduced November 20, 2025 by Frank Pallone · Last progress November 20, 2025
The bill expands price negotiations, rebate adjustments, and hard caps that will lower drug spending for many patients (including insulin protections and an annual cap) but does so in ways that leave gaps — allowing some plans to opt out, narrowing federal benefit protections, raising administrative burdens, and creating incentives for manufacturers or plans to shift costs or limit U.S. supply.
Patients (including Medicare beneficiaries and low-income people) will face substantially lower out-of-pocket prescription drug costs because the bill expands federal negotiation, caps cost-sharing for negotiated drugs, creates a $2,000 annual out-of-pocket cap, and caps insulin cost-sharing.
Medicare beneficiaries and Part D enrollees will likely see more accurate rebate calculations and larger effective rebates because commercial-market utilization is counted and Medicaid/340B units are excluded for certain calculations, which can lower net costs.
Patients (including Medicare beneficiaries) will have more drugs subject to federal price negotiation and those negotiations will be anchored to an average international market price (AIMP), which can push negotiated prices closer to prices in comparable countries.
Workers and people covered by employer/group plans may be left without the bill's lower cost-sharing protections because group health plans and issuers can opt out and the bill narrows federal enforceable benefit standards (EHB/ERISA changes), creating uneven coverage and weaker federal protections.
Patients (especially those needing newer or high-cost therapies) risk reduced access because manufacturers may limit U.S. product availability, delay launches, or change pricing strategies in response to negotiation and rebate rules, which could restrict treatment options or raise costs for some.
Employers, insurers, and state governments will face substantial administrative and compliance costs to implement new reporting, cost‑sharing substitution, multiple caps, indexing rules, and adjusted rebate calculations.
Based on analysis of 4 sections of legislative text.
Extends negotiated maximum fair drug prices beyond Medicare to many private plans, adds international price benchmarking, revises rebate unit rules, and sets new 2027 benefit and cost-sharing limits for commercial markets.
Expands the federal drug price negotiation program and extends negotiated maximum fair prices beyond Medicare to many private group and individual health plans, while changing how prescription drug unit counts and inflation rebates are calculated. It also narrows an existing ACA-era requirement for certain plan benefits beginning in 2027 and sets new mandatory out-of-pocket limits and benefit rules for individual and small-group market plans. The bill requires plans that remain in the program to apply negotiated maximum fair prices to patient cost-sharing, creates an opt-out/voluntary participation regime for plans with public disclosure of opt-outs, adds an international price benchmark to negotiation considerations beginning in 2028, and changes how rebate unit counts are calculated for Parts B and D to include certain commercial-market dispensing. It phases in new consumer cost limits and essential-benefit rules for 2027 plan years and makes related changes to ERISA and the tax code to implement these requirements.