Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]

Bill Number

H.R. 6610

Origin Chamber

House

Congress

119th Congress, Session 1

Policy Area

Health

Status

Introduced

Latest Action

2025-12-11: Referred to the House Committee on Oversight and Government Reform.

Last Updated

2026-07-10T08:06:33Z

AI-Generated Summary

Purpose of the Legislation

The bill, titled the "Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]," aims to regulate pharmacy benefit managers (PBMs)—third-party companies that manage prescription drug benefits—in the Federal Employees Health Benefits (FEHB) Program. It seeks to reduce costs for federal employees and ensure fair payments to pharmacies by limiting PBM practices that could inflate drug prices or favor affiliated pharmacies.

Key Provisions

• Reimbursement Requirements for Pharmacies:
• PBMs must reimburse in-network pharmacies (licensed pharmacies participating in the plan) for the cost of prescription drugs using the national average drug acquisition cost (NADAC, a benchmark for what pharmacies pay for drugs) on the day the claim is processed, or the wholesale acquisition cost (WAC, the manufacturer's list price) if NADAC is unavailable.
• Added to this, PBMs must pay the lesser of 4% of the NADAC/WAC amount or $50 as an ingredient cost adjustment.
• PBMs must also pay a professional dispensing fee (a fixed payment for the pharmacist's work in preparing and providing the drug) equal to the fee set by the state Medicaid program where the pharmacy is located.

• Handling of Manufacturer Rebates:
• PBMs must apply drug manufacturer rebates (discounts given to PBMs or plans) at the point of sale, reducing the coinsurance or copayment (the patient's out-of-pocket share) based on the drug's net cost after rebates.
• Any remaining rebate amount (after the patient reduction) must be passed to the health plan carrier (the insurance company offering the FEHB plan).

• Prohibitions on PBM Practices:
• PBMs cannot direct or require patients to use specific pharmacies, especially their affiliates (related companies, like a PBM-owned pharmacy).
• PBMs cannot promote or market their affiliates over other in-network pharmacies.
• PBMs cannot create networks or rules (e.g., accreditation standards, limits on drug quantities, or delivery methods) that exclude or restrict in-network pharmacies from filling prescriptions.
• PBMs cannot pressure drug manufacturers to limit drug distribution to few pharmacies or non-affiliates.
• PBMs cannot claw back (demand repayment of) dispensing fees from pharmacies or raise patient costs to offset them.
• PBMs cannot adjust or reduce pharmacy reimbursements after a claim is initially processed, including by adding unrelated fees.

• Oversight and Compliance:
• Health plan carriers must allow inspections by the Office of Personnel Management (OPM, the federal agency overseeing FEHB) and provide documents, staff, and facilities as needed.
• Definitions are provided for key terms like "affiliate," "in-network pharmacy," "PBM," and "prescription drug" to clarify scope.

• Penalties for Noncompliance (New Section 8902b):
• OPM can impose $10,000 civil monetary penalties per violation on PBMs; after five violations tied to the same carrier in 10 years, penalties also apply to the carrier.
• Penalty caps: $100,000 total per PBM per carrier over 10 years; $50,000 total per carrier over 10 years.
• After the fifth penalty on a carrier for a PBM, the carrier must submit a remediation plan to ensure future compliance; OPM will inspect to verify it.
• If a PBM receives 10 penalties in 10 years, it faces debarment (barring from FEHB contracts for 90 days after the 10th penalty), prohibiting payments for its services.
• Penalties can be deducted from federal payments owed to violators and recovered via lawsuits by the U.S. Attorney General; recovered funds go to the FEHB Fund.
• Violations must be addressed within 6 years; debarment ends if penalties are overturned on appeal.
• Affected parties have rights to notice, hearings (conducted by an impartial OPM hearing officer), and judicial review in federal court, with limited grounds for overturning decisions (e.g., lack of evidence or abuse of discretion).

• Effective Date: Changes take effect one year after enactment.

Significant Changes to Existing Law

• Amends Section 8904 of Title 5, U.S. Code, by adding new requirements for FEHB plans, ensuring OPM only approves plans with compliant PBM contracts.
• Inserts a new Section 8902b for PBM-specific sanctions, including penalties and debarment, which did not previously exist in the FEHB chapter.
• Updates Section 8903a to require FEHB plan contracts to comply with the new PBM rules, integrating them into broader contracting standards.

These changes introduce direct federal oversight of PBM operations in FEHB, shifting from voluntary practices to mandatory standards focused on transparency and fairness.

Potential Impacts

• On Government Agencies: OPM gains new enforcement powers, including inspections, penalty imposition, and debarment decisions, increasing its administrative workload but enhancing control over FEHB costs (which cover about 8 million federal employees and retirees).
• On Citizens: Federal employees and retirees in FEHB plans may see lower out-of-pocket costs for drugs due to point-of-sale rebate reductions, potentially improving access to medications; however, plan premiums could adjust based on overall cost shifts.
• On International Relations: No direct impact, as the bill focuses on domestic federal health benefits and U.S.-based pharmacies/PBMs.
• Broader effects could include reduced drug costs in the FEHB Program (a large payer), possibly influencing private insurance markets indirectly through precedent.

Main Stakeholders Affected

• Federal Employees and Retirees (Beneficiaries): Gain protections against steered pharmacy use and lower copays via rebates.
• In-Network Pharmacies: Benefit from standardized, fair reimbursements and dispensing fees, reducing financial pressures from PBM adjustments.
• Pharmacy Benefit Managers (PBMs): Face new restrictions, potential fines, and debarment risks, limiting profit strategies like affiliate favoritism or rebate retention.
• Health Plan Carriers: Must ensure PBM compliance, submit remediation plans if penalized, and cooperate with OPM inspections, with shared liability for violations.
• Office of Personnel Management (OPM): Assumes expanded regulatory role in monitoring and enforcing PBM rules.
• Drug Manufacturers: Indirectly affected by prohibitions on distribution limits, potentially broadening drug access.

Notable Legal, Constitutional, or Political Implications

• Legal: Establishes clear due process through hearings and appeals, aligning with administrative law standards (e.g., no reliance on formal rulemaking like the Administrative Procedure Act for hearings). Penalties and debarment provide strong deterrents but include safeguards against arbitrary enforcement. Potential for lawsuits if PBMs challenge reimbursement formulas or prohibitions as overly prescriptive.
• Constitutional: Likely withstands scrutiny under the Spending Clause, as it regulates a federal program (FEHB) funded by taxpayer dollars; no apparent First Amendment issues with marketing bans, as they target commercial practices in a government contract context. Equal protection concerns minimal, as rules apply uniformly to FEHB participants.
• Political: Bipartisan sponsorship (from both parties) signals broad support for curbing PBM influence, amid growing scrutiny of drug pricing. Could set a model for similar reforms in Medicare or private insurance, influencing debates on healthcare costs, but may face opposition from PBM industry lobbying over reduced flexibility and revenues.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Rep. Auchincloss, Jake [D-MA-4]

Cosponsors (37)

Rep. Comer, James [R-KY-1], Rep. Harshbarger, Diana [R-TN-1], Rep. Carter, Earl L. "Buddy" [R-GA-1], Rep. Ciscomani, Juan [R-AZ-6], Rep. Moulton, Seth [D-MA-6], Rep. Deluzio, Christopher R. [D-PA-17], Rep. Tlaib, Rashida [D-MI-12], Rep. Budzinski, Nikki [D-IL-13], Rep. Krishnamoorthi, Raja [D-IL-8], Rep. Khanna, Ro [D-CA-17], Rep. Cohen, Steve [D-TN-9], Rep. Pressley, Ayanna [D-MA-7], Rep. Gonzalez, Vicente [D-TX-34], Rep. Moore, Barry [R-AL-1], Rep. Subramanyam, Suhas [D-VA-10], Rep. Pocan, Mark [D-WI-2], Rep. Bishop, Sanford D. [D-GA-2], Rep. McCollum, Betty [D-MN-4], Rep. Westerman, Bruce [R-AR-4], Rep. Scott, Austin [R-GA-8], Rep. Fleischmann, Charles J. "Chuck" [R-TN-3], Rep. Rogers, Harold [R-KY-5], Rep. Maloy, Celeste [R-UT-2], Rep. McGarvey, Morgan [D-KY-3], Rep. Bergman, Jack [R-MI-1], Rep. Sessions, Pete [R-TX-17], Rep. Clyde, Andrew S. [R-GA-9], Rep. Rogers, Mike D. [R-AL-3], Rep. Aderholt, Robert B. [R-AL-4], Rep. Burchett, Tim [R-TN-2], Rep. Strong, Dale W. [R-AL-5], Rep. Mann, Tracey [R-KS-1], Rep. Langworthy, Nicholas A. [R-NY-23], Rep. Palmer, Gary J. [R-AL-6], Rep. Figures, Shomari [D-AL-2], Rep. Frost, Maxwell [D-FL-10], Rep. McCormick, Richard [R-GA-7]

Recent Actions

• 2025-12-11: Referred to the House Committee on Oversight and Government Reform.
• 2025-12-11: Introduced in House
• 2025-12-11: Introduced in House

Bill Versions

• Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act] — issued 2025-12-11 — PDF (18 pages)