Sponsors (4)
The bill increases Medicaid pharmacy pricing transparency and aims to direct more funds to patient care by curbing PBM spread‑pricing and requiring detailed reporting, but it imposes substantial compliance costs, disclosure risks, and reduces some procedural rulemaking protections that could strain small pharmacies, states, and plans.
State Medicaid programs and HHS will get regular, drug-level pharmacy acquisition benchmarks and greater price transparency, giving states more accurate data to set Medicaid pharmacy payment rates and monitor pricing.
Medicaid beneficiaries and providers could see more appropriate reimbursements and lower net drug costs because pass‑through reporting, prohibitions on spread pricing counting for Federal match, and limits on PBM administrative fees shift more money toward pharmacies and patient care.
Public reporting (non‑identifying state summaries and survey results) and OIG studies increase accountability and can expose abusive related‑party transfers, affiliate pricing, or other practices that distort acquisition cost reporting.
Community and specialty pharmacies face substantial new compliance obligations and risk large civil monetary penalties (up to $100,000 per violation) for nonresponse or false reporting, creating financial and operational risk for small providers.
States and Medicaid managed‑care plans will incur increased administrative and reporting costs to collect and submit detailed drug‑level data to HHS, adding workload and expenses to state budgets and plans.
PBMs and managed care entities may respond to reduced spread pricing and capped fees by raising plan premiums, narrowing formularies, or exiting contracts, which could reduce access or raise costs for Medicaid beneficiaries.
Based on analysis of 3 sections of legislative text.
Requires regular national collection and public reporting of pharmacy drug acquisition prices and creates a new federal rule forcing Medicaid payments from PBMs and similar entities to be passed through in full to pharmacies (with limited exceptions). It adds civil penalties and OIG studies, conditions federal Medicaid matching funds on state contracts that ban PBM spread pricing and require itemized reporting, and funds OIG oversight.
Introduced March 11, 2025 by Peter Welch · Last progress March 11, 2025