Other
Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]
This bill establishes new rules for pharmacy benefit managers (PBMs) that administer prescription drug plans for federal employees and retirees. It requires PBMs to pass drugmaker discounts directly to patients at the checkout counter, lowering copays and coinsurance based on the discounted net cost of medicine. The bill also protects patients' choice of pharmacy by banning PBMs from steering patients toward company-owned pharmacies, preventing unfair fees or pay cuts on local drugstores, and establishing $10,000 fines or program bans for companies that break the rules.
People affected—The text applies to enrollees, carriers, PBMs, and pharmacies participating in federal employee health plans under 5 U.S.C. chapter 89, but does not provide a specific count of individuals affected.
Fiscal magnitude—no CBO estimate published
Reach58provisional · pending reviewrigor: heuristic llm
What this bill touches.
Market protections+40Pharmaceutical pricing+45Corporate concentration+45
Who it helps · who it burdens.
Who it helps
- In-network pharmaciesGuarantees reimbursement based on national or wholesale drug acquisition costs plus up to 4% or $50, ensures professional dispensing fees equal to state Medicaid rates, and prohibits PBMs from imposing clawbacks, retroactive claim fees, or steering enrollees away to affiliated pharmacies (Sec. 2(a)(c)(1)(A)-(C)).
- Federal employee health plan enrolleesReceive point-of-sale reductions on copayments and coinsurance based on manufacturer rebates, and are protected from mandatory steering to PBM-affiliated pharmacies or being charged additional fees for pharmacy dispensing costs (Sec. 2(a)(c)(1)(A)(iii)(I), Sec. 2(a)(c)(1)(B)(i), (v)).
- Federal health plan carriersReceive the remaining balance of manufacturer rebates passed through by PBMs after enrollee cost-sharing reductions are applied (Sec. 2(a)(c)(1)(A)(iii)(II)).
Who it burdens
- Pharmacy benefits managers (PBMs)Subject to strict reimbursement formulas and dispensing fee rules, prohibited from keeping manufacturer rebates or steering enrollees to affiliated pharmacies, prohibited from clawing back fees, and face civil monetary penalties of $10,000 per violation and potential debarment from the federal program for repeated violations (Sec. 2(a)(c)(1), Sec. 2(b)(1)(8902b)(a)-(b)).
- Federal health plan carriersSubject to civil penalties of up to $50,000 per 10-year period for repeat PBM violations, required to submit compliance plans and undergo OPM oversight inspections, and must provide OPM access to personnel, facilities, and records (Sec. 2(a)(c)(1)(D), Sec. 2(b)(1)(8902b)(a)(1)(B), (a)(3)).
Who backs it
- Employees Health Benefits FundReceives all civil monetary penalties recovered from noncompliant PBMs and health plan carriers (Sec. 2(b)(1)(8902b)(a)(5)(B)).