Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]
Sponsored By: Representative Auchincloss
Introduced
Summary
Limits pharmacy benefit manager authority in Federal Employee Health Benefits plans. It would set rules to change how PBMs pay pharmacies, how rebates affect enrollees' costs, and how OPM enforces compliance.
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- In-network pharmacies would get a set ingredient reimbursement equal to the national average drug acquisition cost (NADAC) on the day of claim, or wholesale acquisition cost (WAC) if NADAC is not available, plus the lesser of 4 percent or $50, and a dispensing fee tied to the State Medicaid (Title XIX) fee.
- Federal employees and other FEHB enrollees would see manufacturer rebates applied at the point of sale to reduce coinsurance or copayments based on the drug's net cost, and plans must remit rebate amounts to carriers after that reduction.
- PBMs would face new limits on steering, advertising, narrow networks, post-claim clawbacks, and other practices, and could be hit with civil penalties of $10,000 per violation with caps and a new OPM inspection and remediation regime, plus hearing and judicial review rights.
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Bill Overview
Analyzed Economic Effects
3 provisions identified: 1 benefits, 0 costs, 2 mixed.
Lower drug checkout costs
This bill would require FEHB plans that use PBMs to pay in‑network pharmacies the drug ingredient cost equal to the NADAC on the day of claim adjudication, or WAC if NADAC is not available, plus the smaller of 4% of that amount or $50. It would also require payment of a professional dispensing fee equal to the State Medicaid dispensing fee where the pharmacy is located. Manufacturer rebates for drugs bought in network would be applied at the point of sale to lower your coinsurance or copay, and PBMs would have to send the remaining rebate to the FEHB carrier. PBMs would be barred from cutting a paid claim after adjudication, steering you to certain pharmacies, or using networks that exclude in‑network pharmacies. These rules would take effect one year after enactment.
Clear PBM and pharmacy terms
The bill would add clear definitions for affiliate, beneficiary, in‑network pharmacy, pharmacy benefits manager, PBM services, and prescription drug for FEHB rules. It would also make following the new PBM and pharmacy rules a condition for a carrier to participate in the FEHB program. These definitional and compliance changes would take effect one year after enactment.
Fines and debarment for PBMs
The bill would let OPM, after consulting the Attorney General, impose a $10,000 civil penalty for each PBM violation of the new FEHB PBM rules. Penalties on a PBM for a carrier's plans would be capped at $100,000 in any 10‑year period, and penalties on a carrier would be capped at $50,000 in any 10‑year period. If a PBM gets 10 or more penalties in any 10‑year period, OPM would debar the PBM from FEHB business (debarment effective 90 days after the penalty that triggers it). The Attorney General could sue to collect penalties, recovered amounts would go to the Employees Health Benefits Fund, OPM could deduct penalties from amounts the United States owes the party, and OPM would inspect carriers and require remediation plans after repeated penalties. OPM could not start penalty actions later than 6 years after a violation.
Sponsors & CoSponsors
Sponsor
Auchincloss
MA • D
Cosponsors
Rep. Comer, James [R-KY-1]
KY • R
Sponsored 12/11/2025
Rep. Harshbarger, Diana [R-TN-1]
TN • R
Sponsored 12/11/2025
Rep. Carter, Earl L. "Buddy" [R-GA-1]
GA • R
Sponsored 12/11/2025
Ciscomani
AZ • R
Sponsored 12/11/2025
Rep. Moulton, Seth [D-MA-6]
MA • D
Sponsored 12/11/2025
Rep. Deluzio, Christopher R. [D-PA-17]
PA • D
Sponsored 12/11/2025
Rep. Tlaib, Rashida [D-MI-12]
MI • D
Sponsored 12/11/2025
Budzinski
IL • D
Sponsored 12/11/2025
Rep. Krishnamoorthi, Raja [D-IL-8]
IL • D
Sponsored 12/11/2025
Khanna
CA • D
Sponsored 12/11/2025
Cohen
TN • D
Sponsored 12/11/2025
Rep. Pressley, Ayanna [D-MA-7]
MA • D
Sponsored 12/11/2025
Gonzalez, V.
TX • D
Sponsored 12/11/2025
Rep. Moore, Barry [R-AL-1]
AL • R
Sponsored 12/11/2025
Rep. Subramanyam, Suhas [D-VA-10]
VA • D
Sponsored 12/11/2025
Rep. Pocan, Mark [D-WI-2]
WI • D
Sponsored 12/11/2025
Bishop
GA • D
Sponsored 12/11/2025
McCollum
MN • D
Sponsored 12/11/2025
Rep. Westerman, Bruce [R-AR-4]
AR • R
Sponsored 12/23/2025
Rep. Scott, Austin [R-GA-8]
GA • R
Sponsored 1/7/2026
Rep. Fleischmann, Charles J. "Chuck" [R-TN-3]
TN • R
Sponsored 1/7/2026
Rogers (KY)
KY • R
Sponsored 1/7/2026
Maloy
UT • R
Sponsored 1/7/2026
Rep. McGarvey, Morgan [D-KY-3]
KY • D
Sponsored 1/7/2026
Rep. Bergman, Jack [R-MI-1]
MI • R
Sponsored 1/9/2026
Sessions
TX • R
Sponsored 1/9/2026
Rep. Clyde, Andrew S. [R-GA-9]
GA • R
Sponsored 1/30/2026
Rep. Rogers, Mike D. [R-AL-3]
AL • R
Sponsored 2/4/2026
Aderholt
AL • R
Sponsored 2/9/2026
Rep. Burchett, Tim [R-TN-2]
TN • R
Sponsored 4/14/2026
Rep. Strong, Dale W. [R-AL-5]
AL • R
Sponsored 4/14/2026
Rep. Mann, Tracey [R-KS-1]
KS • R
Sponsored 4/21/2026
Langworthy
NY • R
Sponsored 5/4/2026
Rep. Palmer, Gary J. [R-AL-6]
AL • R
Sponsored 5/14/2026
Roll Call Votes
No roll call votes available for this bill.
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