Sponsors (57)
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 aims to lower prescription drug costs and protect consumers (notably via expanded negotiation, insulin caps, and a $2,000 annual OOP cap) but does so at the risk of market reactions that could limit drug availability, uneven protections for people in employer plans, increased administrative costs, and potential future increases in caps if premiums rise.
Patients with high‑cost drugs (including Medicare beneficiaries) would pay less because the bill expands federal negotiation, requires price anchors tied to international averages, and limits cost‑sharing for selected negotiated drugs.
Medicare Part B and Part D beneficiaries (and plans) could see lower net drug spending because rebate/billing‑unit calculations are adjusted to include commercial utilization and exclude certain non‑commercial units, focusing rebates on commercial market use.
People with diabetes would face much lower insulin out‑of‑pocket costs due to a $35 per 30‑day supply cap (or 25% of the negotiated price) starting in 2027.
Patients could face fewer treatment options if manufacturers respond to lower negotiated prices by delaying U.S. launches or reducing product availability.
Workers and people covered by employer/group plans may lose federal benefit protections — some group plans can opt out of lower cost‑sharing, and narrowing of federal EHB/ERISA incorporation reduces enforceable standards for many employer plans.
Indexing the new out‑of‑pocket caps to premium growth could allow large increases in future caps if premiums rise, exposing consumers to much higher out‑of‑pocket spending over time.
Based on analysis of 4 sections of legislative text.
Expands Medicare drug price negotiation and applies negotiated maximum fair prices to many private plans, revises rebate/unit counting, and sets 2027 cost‑sharing caps and EHB requirements.
Expands the federal drug price negotiation program and applies negotiated maximum fair prices beyond Medicare to many private group and individual health plans, while changing how manufacturer rebate unit counts are calculated. It also imposes new consumer protections in the individual and small-group markets, including required essential health benefits, new caps on prescription drug out‑of‑pocket costs and overall cost‑sharing limits for plan years beginning in 2027, and a new international price benchmark for future negotiations starting in 2028. The bill creates a default, voluntary opt‑out regime for private plans (so plans are treated as participating unless they affirmatively decline), requires public disclosure of opt‑outs, amends ERISA and the Internal Revenue Code to extend price applicability, and repeals a recent statutory change. Several technical changes adjust Part B and Part D rebate/unit accounting to include or exclude certain commercial market units and 340B discounts when computing manufacturer rebates.