Sponsors (42)
Imposes PBM transparency and conduct rules in Medicare Part D, sets NADAC/WAC-based pharmacy reimbursements, requires Medicaid pharmacy acquisition price surveys, and authorizes penalties for violations.
The bill increases transparency, forces rebates to lower patients' point-of-sale costs, and strengthens oversight of PBMs while protecting retail pharmacies, but it also raises compliance and reporting burdens, risks unintended price-shifting and higher premiums, and creates confidentiality and competition concerns.
Medicare Part D enrollees (especially people with chronic conditions) pay lower point-of-sale cost-sharing because manufacturer rebates must be applied to reduce coinsurance/copays at the pharmacy.
Patients gain stronger consumer protections and visibility into drug pricing because PBM gag clauses and steering are prohibited and PBMs must disclose rebate and financial information.
State Medicaid programs and Medicaid beneficiaries benefit from improved rebate remittances and better national data on pharmacy acquisition prices, increasing state funds and supporting more accurate Medicaid reimbursement decisions.
Medicare beneficiaries and taxpayers risk higher Part D premiums or reduced plan offerings if PBMs and plan sponsors pass compliance costs onto premiums or scale back benefits.
Drug manufacturers and PBMs may alter rebate structures or list prices in response, shifting costs elsewhere in the supply chain and creating new unintended price effects for patients and payers.
Pharmacies—particularly small or independent ones—face increased administrative and compliance burdens to collect and report net acquisition prices and concessions, raising operating costs.
Based on analysis of 3 sections of legislative text.
Official title: To amend titles XI, XVIII, and XIX of the Social Security Act to establish certain requirements under Medicare and Medicaid with respect to prescription drug benefits and pharmacy benefit managers.
Introduced December 11, 2025 by Jake Auchincloss · Last progress December 11, 2025
Creates new federal rules for pharmacy benefit managers (PBMs) that serve Medicare Part D plans and expands pharmacy price reporting in Medicaid. It bans certain PBM practices (like spread pricing and steering), requires rebate pass-through and formulary transparency, sets minimum reimbursement tied to NADAC/WAC plus a dispensing fee, requires audits and recordkeeping, and authorizes penalties and contract termination for violations. States must collect and report pharmacy acquisition price survey data for Medicaid drugs and may not use non-retail prices to set retail reimbursement.