H.R. 5197

119th CONGRESS 1st Session

To amend title XVIII of the Social Security Act to limit cost sharing for drugs under the Medicare program.

IN THE HOUSE OF REPRESENTATIVES · September 8, 2025 · Sponsor: Ms. Malliotakis

Table of contents

• H.R. 5197
  • SEC. 1. Short title
  • SEC. 2. Limitation on cost sharing to net price amount under Medicare part D

SEC. 1. Short title

• This Act may be cited as the Protect Beneficiaries from Middlemen Act.

SEC. 2. Limitation on cost sharing to net price amount under Medicare part D

• (a) In general
  • Section 1860D–2 of the Social Security Act () is amended— 42 U.S.C. 1395w–102
    • in subsection (b)—
      • in paragraph (2)(A), by striking (8) and (9)and inserting (8), (9), and (10);
      • in paragraph (9)(B)(ii), by striking For a plan yearand inserting Subject to paragraph (10), for a plan year; and
        • (10) Limitation on cost sharing to net price amount
          • (A) In general
            • For a plan year beginning on or after January 1, 2027, the coverage provides benefits for a supply of a covered part D drug dispensed by a pharmacy, for costs in excess of the deductible specified in paragraph (1) and prior to an individual reaching the out-of-pocket threshold under paragraph (4), with cost-sharing for a month’s supply that does not exceed the average net price for such a supply of such drug during such plan year (or, if lower, the applicable cash price for such a supply of such drug so dispensed by such pharmacy).
          • (B) Definitions
            • In this paragraph:
              • (i) The term means, with respect to a supply of a covered part D drug dispensed by a pharmacy, the price that such pharmacy would charge for such supply of such drug dispensed to an individual without benefits for such drug under any Federal health care program (as defined in section 1128B), a group health plan or group or individual health insurance coverage (as such terms are defined in section 2791 of the Public Health Service Act), or the program established under of title 5, United States Code. applicable cash price chapter 89
              • (ii) The term means, with respect to a supply of a covered part D drug, a prescription drug plan, and a plan year, the average amount paid under such plan (including any amounts paid by an individual enrolled under such plan as cost sharing for such drug) as payment for such a supply of such drug dispensed during such year, less any rebates or other forms of remuneration received under such plan with respect to such drug. average net price
      • by adding at the end the following new paragraph:
      • (7) Cost sharing limited to net price
        • The coverage is provided in accordance with subsection (b)(10).
    • in subsection (c), by adding at the end the following new paragraph:
• (b) Conforming amendment to cost-Sharing for low-Income individuals
  • Section 1860D–14(a)(1)(D)(iii) of the Social Security Act () is amended by adding at the end the following new sentence: . For plan year 2027 and subsequent plan years, the copayment amount applicable under this clause to a supply of a covered part D drug dispensed to the individual may not exceed the amount provided under section 1860D–2(b)(10). 42 U.S.C. 1395w–114(a)(1)(D)(iii)
• (c) GAO report
  • Not later than January 1, 2029, the Comptroller General of the United States shall submit to Congress a report containing—
    • an analysis of compliance with the amendments made by this section;
    • an analysis of enforcement of such amendments;
    • recommendations with respect to improving such enforcement; and
    • recommendations relating to improving public disclosure, and public awareness of, the requirements of such amendments.