Sponsors (71)
Introduced July 10, 2025 by Buddy Carter · Last progress July 10, 2025
The bill increases transparency, oversight, and patient access protections across Medicare, Medicaid, and commercial pharmacy benefit management—potentially lowering hidden middle‑man profits and improving pharmacy payments—while imposing substantial new reporting, compliance, and enforcement costs that could be passed to beneficiaries, providers, and state budgets and raise privacy and competitive‑risk concerns.
Medicare, Medicaid, employers, and commercial plan enrollees gain far greater price transparency because PBMs, plan sponsors, and manufacturers must report drug‑level net prices, rebates, spread, and retained amounts in standardized, machine‑readable formats.
Medicare and Medicaid beneficiaries and local communities could see improved pharmacy access and more predictable pharmacy payments because plans must permit qualifying pharmacies to join networks, certain pharmacies receive 'essential' protections, and Medicaid pass‑through pricing and full pharmacy payments reduce hidden spread pricing.
Plan sponsors and beneficiaries benefit from stronger PBM rules—PBMs must act as fiduciaries, gag clauses are banned, and steering/discriminatory reimbursement practices are prohibited—reducing conflicts of interest and improving alignment with plan finances.
Medicare and commercial beneficiaries and taxpayers may face higher premiums or program costs because requiring plans to accept more pharmacies and imposing extensive reporting/enforcement obligations can increase plan and PBM operating costs that are often passed on.
PBMs, plans, pharmacies, and state regulators face substantial new administrative and compliance burdens (frequent machine‑readable reporting, audits, licensing and survey requirements) that could prompt vendor consolidation, market exits, higher vendor fees, or reduced plan offerings.
Detailed, frequent reporting (including transaction‑level or claims data) and exemptions from Paperwork Reduction Act or notice‑and‑comment create elevated privacy and data‑security risks for patients if protected health information is mishandled.
Based on analysis of 8 sections of legislative text.
Creates wide PBM transparency, anti‑spread/pricing rules, pass‑through payments to pharmacies, machine‑readable drug‑level reporting, and new enforcement across Medicare Part D, Medicaid, and group plans.
Requires pharmacy benefit managers (PBMs), Medicare Part D sponsors, Medicaid contractors, group health plans, and health insurers to increase transparency, limit spread pricing and certain remuneration, and pass through payments to dispensing pharmacies. The bill forces PBMs to disclose contracts, rebate and pricing information, obtain licenses/registrations, adopt fiduciary/transparency duties, and face civil penalties and contract sanctions for violations. Effects are phased in: many Medicare Part D changes apply to plan years beginning in 2028–2029; Medicaid pass‑through pricing and other changes take effect about 18 months after enactment; group health plan and PBM reporting provisions begin about 30 months after enactment. The law also creates new federal reporting and survey duties, requires machine‑readable drug‑level claim reports, and expands HHS/CMS enforcement authority.