Patients Before Middlemen Act
Patients Before Middlemen Act
Plain Language Summary
# Patients Before Middlemen Act Summary **What the Bill Does:** This bill aims to regulate pharmacy benefit managers (PBMs)—companies that manage prescription drug benefits for insurance plans—and set stricter rules for how they work with pharmacies and insurers under Medicare programs. It would require the government to establish standards for contracts between drug plan sponsors and pharmacies, create reporting requirements to track pharmacy costs and practices, and impose financial penalties on companies that violate these standards. **Who It Affects:** The bill primarily impacts Medicare beneficiaries (seniors and disabled individuals), pharmacies (especially small or rural ones), pharmacy benefit managers, and prescription drug plan sponsors. It's designed to protect patients and independent pharmacies from what supporters view as unfair middleman practices that drive up costs. **Key Provisions:** The bill requires Medicare's regulatory agency (CMS) to develop fair contract standards, imposes penalties for violations, and mandates reporting on essential pharmacies—particularly those serving as the only option in their area.
It also includes language restricting how PBMs can generate income, though the bill summary is incomplete on this point. **Current Status:** The bill is currently in committee and has not yet been voted on by the full Senate. No action has been taken since its introduction.
CRS Official Summary
Patients Before Middlemen ActThis bill establishes certain standards and reporting requirements for prescription drug plan (PDP) sponsors, pharmacy benefit managers (PBMs), and pharmacies under the Medicare prescription drug benefit and Medicare Advantage.Specifically, the Centers for Medicare & Medicaid Services (CMS) must develop reasonable and relevant standards for contracts between PDP sponsors and pharmacies. The CMS must seek input from interested stakeholders when developing these standards. PDP sponsors are subject to civil penalties for violating these standards; PBMs must reimburse PDP sponsors for civil penalties that result from their responsibilities.The bill also requires the CMS to report periodically on essential retail pharmacies (i.e., pharmacies that serve as the only pharmacy within a certain radius) with respect to costs, contracts, and other specified information, particularly in relation to other types of pharmacies.Additionally, PBMs may not receive any income other than flat, bona fide service fees. PBMs must turn over any excess amounts they receive to PDP sponsors; PDP sponsors must turn over these amounts to the CMS. In addition, PBMs must report to PDP sponsors and to the CMS an itemized list of prescription drugs that were dispensed during the previous year and related data about costs, claims, affiliated pharmacies, and other specified information. PDP sponsors may audit PBMs to ensure compliance with these requirements and must annually certify their compliance; PBMs are responsible for any associated civil penalties for violations.The bill's changes generally apply beginning in 2028.
Latest Action
Read twice and referred to the Committee on Finance.