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Changes Medicare Part D cost-sharing for certain chronic-care drugs so patients pay no more than the drug's net price before the deductible and coinsurance (between deductible and out-of-pocket threshold) is calculated as a percentage of the drug's net price, with limited exceptions. The rule also aligns low-income subsidy cost rules with the same net-price approach. These rules apply to plan years starting on or after January 1, 2027, and the HHS Secretary must implement the change initially by interim final regulations. The covered drugs are those identified by specific USP categories referenced in Medicare Model Guidelines.
Amends section 1860D–2(b) of the Social Security Act by adding paragraph (10) titled 'Cost-sharing for chronic care drugs.' This new paragraph establishes special cost-sharing rules for chronic care drugs beginning in plan years on or after January 1, 2027.
For plan years beginning on or after January 1, 2027, when a covered drug is a 'chronic care drug': (i) for costs below the annual deductible, the enrollee's cost-sharing for that drug may not exceed the drug's net price; (ii) for costs above the annual deductible and below the out-of-pocket threshold, any coinsurance must be based on a percentage of the drug's net price (subject to the stated exception).
Exception: The coinsurance-percentage requirement does not apply to a chronic care drug under a prescription drug plan if the plan's cost-sharing for that drug is a copayment that is not tied to a percentage of a drug price, benchmark price, or drug cost (for example, a flat copayment).
Defines 'chronic care drug' by listing covered Part D drug categories from the USP Medicare Model Guidelines: (I) blood glucose regulators (non-insulin); (II) anti-inflammatories, inhaled corticosteroids; (III) bronchodilators, anticholinergic; (IV) bronchodilators, sympathomimetic; (V) respiratory tract agents, other; (VI) anticoagulants; (VII) cardiovascular agents, other; and (VIII) any successor USP categories/classes identified by the Secretary or USP based on the most recent USP Medicare Model Guidelines.
Defines 'net price' to mean the negotiated price of the drug net of all manufacturer price concessions received or expected to be received by the plan or pharmacy benefit manager on behalf of the plan that are not already reflected in the negotiated price.
Primary effects:
Last progress September 11, 2025 (5 months ago)
Introduced on September 11, 2025 by John Cornyn
Read twice and referred to the Committee on Finance.