Pharmacists Fight Back in Medicare and Medicaid Act
Sponsored By: Representative Auchincloss
Introduced
Summary
Would standardize PBM payment, rebate pass-through, and transparency rules across Medicare Part D and Medicaid. It would set a clear pharmacy payment formula, require point-of-sale rebate reductions to lower patient cost sharing, and create civil and criminal penalties for noncompliance.
Show full summary
- Medicare and Medicaid enrollees would have rebates applied at the point of sale to reduce coinsurance or copays for covered Part D drugs, so out-of-pocket shares reflect those rebates.
- Pharmacies and dispensing sites would get ingredient payments equal to NADAC or, if unavailable, WAC plus 4 percent of that price capped at $50, plus the State-reported dispensing fee. Contracts may not let PBMs or sponsors impose fees that reduce the pharmacy's receipts and would expand acquisition-price survey reporting across many pharmacy types.
- PBMs, plan sponsors, and States would face new written-agreement, anti-steering, rebate remittance, and reporting rules, annual PBM certification to sponsors and the Secretary by July 1, 2028, and felony penalties up to $1,000,000 and 10 years imprisonment with matching civil fines.
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Bill Overview
Analyzed Economic Effects
2 provisions identified: 1 benefits, 0 costs, 1 mixed.
Medicaid PBM and pharmacy payments
If enacted, contracts that start January 1, 2027 or later would require PBMs and similar entities to pay pharmacies NADAC on the claim date (or WAC if no NADAC) plus 4% of that amount, with the 4% part capped so it cannot exceed $50 per claim, plus the State plan dispensing fee. PBMs and entities would have to remit manufacturer rebates or discounts they receive to the State. Pharmacies that get any payment or price concession for covered outpatient drugs would need to respond to state or federal surveys and report acquisition price net of concessions (or the negotiated price if net cost is unknown). The Secretary would publish national acquisition price survey data, and States could not use non-retail pharmacy pricing to set retail reimbursement rates. Title XIX federal payment to States would be conditioned on contract compliance with these rules.
New Medicare Part D drug rules
If enacted, for plan years beginning January 1, 2027, in-network pharmacies would be paid NADAC on the claim date (or WAC if no NADAC) plus 4% of that amount, with the 4% portion capped so it cannot exceed $50 per claim. Plans and PBMs would also have to pay the State Medicaid dispensing fee to in-network pharmacies and could not require you to reimburse that fee. Manufacturer rebates for covered Part D drugs would have to be applied at point of sale to reduce your coinsurance or copay, and the PBM must remit the remaining rebate to the plan sponsor. PBMs (and affiliates) would need to certify compliance annually starting July 1, 2028. Knowing and willful violations would carry criminal fines up to $1,000,000 and/or up to 10 years imprisonment, and civil penalties of $1,000,000 per act would also apply.
Sponsors & CoSponsors
Sponsor
Auchincloss
MA • D
Cosponsors
Harshbarger
TN • R
Sponsored 12/11/2025
Comer
KY • R
Sponsored 12/11/2025
Carter (GA)
GA • R
Sponsored 12/11/2025
Ciscomani
AZ • R
Sponsored 12/11/2025
Moulton
MA • D
Sponsored 12/11/2025
Deluzio
PA • D
Sponsored 12/11/2025
Peters
CA • D
Sponsored 12/11/2025
Tlaib
MI • D
Sponsored 12/11/2025
Budzinski
IL • D
Sponsored 12/11/2025
Krishnamoorthi
IL • D
Sponsored 12/11/2025
Khanna
CA • D
Sponsored 12/11/2025
Lynch
MA • D
Sponsored 12/11/2025
Goldman (TX)
TX • R
Sponsored 12/11/2025
Cohen
TN • D
Sponsored 12/11/2025
Pressley
MA • D
Sponsored 12/11/2025
Gonzalez, V.
TX • D
Sponsored 12/11/2025
Moore (AL)
AL • R
Sponsored 12/11/2025
Subramanyam
VA • D
Sponsored 12/11/2025
Pocan
WI • D
Sponsored 12/11/2025
Bishop
GA • D
Sponsored 12/11/2025
McCollum
MN • D
Sponsored 12/11/2025
Westerman
AR • R
Sponsored 12/23/2025
Scott, Austin
GA • R
Sponsored 1/7/2026
Fleischmann
TN • R
Sponsored 1/7/2026
Rogers (KY)
KY • R
Sponsored 1/7/2026
Fulcher
ID • R
Sponsored 1/7/2026
Maloy
UT • R
Sponsored 1/7/2026
McGarvey
KY • D
Sponsored 1/7/2026
Bergman
MI • R
Sponsored 1/9/2026
Sessions
TX • R
Sponsored 1/9/2026
Clyde
GA • R
Sponsored 1/30/2026
Rogers (AL)
AL • R
Sponsored 2/4/2026
Aderholt
AL • R
Sponsored 2/9/2026
Williams (TX)
TX • R
Sponsored 2/23/2026
Roll Call Votes
No roll call votes available for this bill.
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