H.R. 6610: Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]

This bill, titled the Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act], seeks to amend the portion of U.S. law that governs Federal employee health benefit plans, particularly focusing on the role of pharmacy benefit managers (PBMs) in relation to these plans. The essential objectives of the bill include:

1. Regulation of Pharmacy Benefit Managers

The bill establishes new requirements for PBMs that administer prescription drug benefits under health plans for federal employees. These requirements include:

• Reimbursement Structure: PBMs must reimburse in-network pharmacies based on two criteria: the national average drug acquisition cost (or the wholesale acquisition cost for drugs not listed) plus a margin that cannot exceed 4% or $50.
• Professional Fees: The bill mandates that PBMs pay pharmacies a professional dispensing fee, consistent with state laws under Medicaid.
• Rebates: Any rebates received by PBMs from manufacturers must be used to lower the out-of-pocket costs for individuals at the point of sale, and PBMs must remit the net rebate amount to the insurer.

2. Prohibitions on PBM Practices

The legislation prohibits various practices by PBMs, including:

• Directing individuals to specific pharmacies, including those affiliated with the PBM, to fill prescriptions.
• Advertising or promoting certain pharmacies over others within the same network.
• Imposing restrictions or conditions that limit the ability of pharmacies to fill prescriptions, or influencing manufacturers to limit drug distribution to certain pharmacies.
• Requiring individuals to reimburse the PBM for dispensing fees charged by pharmacies.

3. Compliance Monitoring and Penalties

The bill establishes a framework for monitoring compliance and enforcing penalties against PBMs:

• Penalties for Violations: PBMs can face civil penalties of $10,000 for each violation of these regulations, with a cap of $100,000 in penalties over ten years for each PBM for the same carrier.
• Remediation Plans: If a PBM accumulates multiple violations, the associated health insurer must submit a plan to ensure future compliance.
• Debarment: PBMs can be barred from managing prescription drug benefits if they incur ten or more penalties in ten years.

4. Hearings and Due Process

The bill ensures that PBMs and insurers have the right to a hearing before adverse actions are taken against them. This includes notifications and opportunities to contest findings related to compliance failures.

5. Definitions

Key terms are defined to clarify the bill's provisions, including what constitutes an "affiliate," "in-network pharmacy," "beneficiary," and "pharmacy benefits management services."

6. Effective Date

The amendments introduced by the bill are set to take effect one year after the bill is enacted.

Relevant Companies

• CVS: As a major pharmacy chain and PBM, the bill may affect how CVS operates in terms of dispensing fees and pricing structures.
• UNH: UnitedHealth Group, which operates its own PBM services, might need to adjust practices and pricing regarding its pharmacy benefits.
• ANTM: Anthem Inc. may also be significantly impacted as it manages pharmacy benefits under its health plans.
• MSFT: Microsoft, as an employer that provides health benefits, could potentially feel indirect effects on its healthcare costs and employee benefit structures.