,i  #aaf? ,,congress  #a/ ,session  ,h4 
,r4 #ecjd  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,decemb] #d1 #bjai,mr4
 ,s*rad] 7= himself & ,mr4 ,gian=te7    
introduc$ ! foll[+ bill2 :i* 0 ref]r$ to
 ! ,committee on ,en]gy & ,comm]ce  ,a  
,,bill  ,to am5d title ,,xxvii ( !      
,public ,heal? ,s]vice ,act to require  
heal? plan ov]sight ( ph>macy b5efit    
manag] s]vices1 & = o!r purposes4  #a4  
,%ort title ,?is ,act may be cit$ z !   
,,pbm ,transp>5cy 9 ,prescription ,drug 
,co/s ,act4  #b4 ,heal? plan ov]sight ( 
ph>macy b5efit manag] s]vices ,subp>t   
,,ii ( "p ,a ( title ,,xxvii ( ! ,public
 ,heal? ,s]vice ,act 7#db ,u4,s4,c4     
#cjj;gg-#aa et seq47 is am5d$ by add+ at
 ! end ! foll[+3  #bgbi;,a4 ,heal? plan 
ov]sight ( ph>macy b5efit manag] s]vices
  7a7 ,9 g5]al ,a gr\p heal? plan or    
heal? insurance issu] (f]+ gr\p or      
individual heal? insurance cov]age or an
 entity or subsidi>y provid+ ph>macy    
b5efits managem5t s]vices %all n ent]   
into a contract ) a drug manufactur]1   

di/ributor1 :olesal]1 subcontractor1    
rebate aggregator1 or any associat$ ?ird
 p>ty t limits ! disclosure ( in=mation 
to plan sponsors 9 su* a mann] t prev5ts
 ! plan or cov]age1 or an entity or     
subsidi>y provid+ ph>macy b5efits       
managem5t s]vices on behalf ( a plan or 
cov]age f mak+ ! reports describ$ 9     
subsection 7b74  7b7 ,reports to gr\p   
plan sponsors  7#a7 ,9 g5]al ,beg9n+ ) !
 fir/ plan ye> t beg9s aft] ! date (    
enactm5t ( ?is section1 n less frequ5tly
 ?an once e six mon?s1 a heal? insurance
 issu] (f]+ gr\p heal? insurance cov]age
 or an entity provid+ ph>macy b5efits   
managem5t s]vices on behalf ( a gr\p    
heal? plan %all submit to ! self-fund$  
gr\p heal? plan & at ! reque/ ( any o!r 
gr\p heal? plan a report 9 accordance ) 
?is subsection & make su* report        
available to ! plan sponsor 9 a         
ma*9e-readable =mat4 ,ea* su* report    
%all include1 ) respect to ! applicable 
gr\p heal? plan or heal? insurance      
cov]age--  7,a7 in=mation collect$ f    

drug manufactur]s by su* issu] or entity
 on ! total am\nt ( copaym5t assi/ance  
doll>s paid1 or copaym5t c>ds appli$1 t 
7 fund$ by ! drug manufactur] ) respect 
to ! enrollees 9 su* plan or cov]age2   
7,b7 a li/ ( ea* cov]$ drug disp5s$ dur+
 ! report+ p]iod1 includ+1 ) respect to 
ea* su* drug dur+ ! report+ p]iod--  7i7
 ! br& "n1 *emical entity1 & ,national  
,drug ,code2  7ii7 ! numb] ( enrollees =
 :om ! drug 0 fill$ dur+ ! plan ye>1 !  
total numb] ( prescription fills = !    
drug 7includ+ orig9al prescriptions &   
refills71 & ! total numb] ( dosage units
 ( ! drug disp5s$ across ! plan ye>1    
includ+ :e!r ! disp5s+ *annel 0 by      
retail1 mail ord]1 or specialty ph>macy2
  7iii7 ! :olesale acquisition co/1 li/$
 z co/ p] days supply & co/ p] pill1 or 
9 ! case ( a drug 9 ano!r =m1 p] dose2  
7iv7 ! total out-(-pocket sp5d+ by      
enrollees on su* drug1 includ+ enrollee 
sp5d+ ?r\gh copaym5ts1 co9surance1 &    
d$uctibles2 &  7v7 = any drug = :i*     
gross sp5d+ ( ! gr\p heal? plan or heal?

 insurance cov]age exce$$ #aj1jjj dur+ !
 report+ p]iod--  7,i7 a li/ ( all o!r  
available drugs 9 ! same !rapeutic      
category or class1 includ+ br& "n drugs 
& biological products & g5]ic drugs or  
biosimil> biological products t are 9 ! 
same !rapeutic category or class2 &     
7,,ii7 ! rationale = pref]r$ =mul>y     
placem5t ( a p>ticul> drug or drugs 9 t 
!rapeutic category or class2  7,c7 a li/
 ( ea* !rapeutic category or class (    
drugs t 7 disp5s$ "u ! heal? plan or    
heal? insurance cov]age dur+ ! report+  
p]iod1 &1 ) respect to ea* su* !rapeutic
 category or class ( drugs1 dur+ !      
report+ p]iod--  7i7 total gross sp5d+  
by ! plan1 be=e manufactur] rebates1    
fees1 or o!r manufactur] remun]ation2   
7ii7 ! numb] ( enrollees :o fill$ a     
prescription = a drug 9 t category or   
class2  7iii7 if applicable to t        
category or class1 a description ( !    
=mul>y ti]s & utilization me*anisms 7su*
 z prior au?orization or /ep !rapy7     
employ$ = drugs 9 t category or class2  

7iv7 ! total out-(-pocket sp5d+ by      
enrollees1 includ+ enrollee sp5d+ ?r\gh 
copaym5ts1 co9surance1 & d$uctibles2 &  
7v7 = ea* !rapeutic category or class "u
 :i* ?ree or m drugs are m>ket$ &       
available-- 7,i7 ! am\nt receiv$1 or    
expect$ to be receiv$1 f drug           
manufactur]s 9 rebates1 fees1 alt]native
 disc\nts1 or o!r remun]ation--  7aa7 to
 be paid by drug manufactur]s = claims  
incurr$ dur+ ! report+ p]iod2 or  7bb7 t
 is relat$ to utilization ( drugs1 9 su*
 !rapeutic category or class2  7,,ii7 ! 
total net sp5d+ by ! heal? plan or heal?
 insurance cov]age on t category or     
class ( drugs2 &  7,,iii7 ! net price p]
 dosage unit or c\rse ( treatm5t incurr$
 by ! heal? plan or heal? insurance     
cov]age & its enrollees1 aft]           
manufactur] rebates1 fees1 & o!r        
remun]ation = drugs disp5s$ )9 su*      
!rapeutic category or class dur+ !      
report+ p]iod2  7,d7 total gross sp5d+  
on prescription drugs by ! plan or      
cov]age dur+ ! report+ p]iod1 be=e      

rebates & o!r manufactur] fees or       
remun]ation2  7,e7 total am\nt receiv$1 
or expect$ to be receiv$1 by ! heal?    
plan or heal? insurance cov]age 9 drug  
manufactur] rebates1 fees1 alt]native   
disc\nts1 & all o!r remun]ation receiv$ 
f ! manufactur] or any ?ird p>ty relat$ 
to utilization ( drug or drug sp5d+ "u t
 heal? plan or heal? insurance cov]age  
dur+ ! report+ p]iod2  7,f7 ! total net 
sp5d+ on prescription drugs by ! heal?  
plan or heal? insurance cov]age dur+ !  
report+ p]iod2 &  7,g7 am\nts paid      
directly or indirectly 9 rebates1 fees1 
or any o!r type ( remun]ation to brok]s1
 consultants1 advisors1 or any o!r      
individual or firm :o ref]r$ ! gr\p     
heal? plan's or heal? insurance issu]'s 
bus9ess to ! ph>macy b5efit manag]4     
7#b7 ,privacy requirem5ts ,heal?        
insurance issu]s (f]+ gr\p heal?        
insurance cov]age & entities provid+    
ph>macy b5efits managem5t s]vices on    
behalf ( a gr\p heal? plan %all provide 
in=mation "u p>agraph 7#a7 9 a mann]    

consi/5t ) ! privacy1 security1 & brea* 
notification regulations promulgat$ "u  
section #bfd7;c7 ( ! ,heal? ,insurance  
,portability & ,acc\ntability ,act (    
#aiif 7or successor regulations71 & %all
 re/rict ! use & disclosure ( su*       
in=mation accord+ to su* privacy        
regulations4  7#c7 ,disclosure &        
r$isclosure  7,a7 ,limitation to bus9ess
 associates ,a gr\p heal? plan receiv+ a
 report "u p>agraph 7#a7 may disclose   
su* in=mation only to bus9ess associates
 ( su* plan z def9$ 9 section #afj4ajc (
 title #de1 ,code ( ,f$]al ,regulations 
7or successor regulations74  7,b7       
,cl>ification reg>d+ public disclosure (
 in=mation ,no?+ 9 ?is section prev5ts a
 heal? insurance issu] (f]+ gr\p heal?  
insurance cov]age or an entity provid+  
ph>macy b5efits managem5t s]vices on    
behalf ( a gr\p heal? plan f plac+      
reasonable re/rictions on ! public      
disclosure ( ! in=mation conta9$ 9 a    
report describ$ 9 p>agraph 7#a74  7c7   
,limitations on spread pric+  7#a7      

,pass-?r\gh (f]+ to plan  ,a designat$  
plan adm9i/rator ( an applicable        
self-insur$ heal? plan1 or an entity    
provid+ ph>macy b5efit managem5t s]vices
 to su* heal? plan %all (f] at lea/ "o  
contractual arrangem5t t does n *>ge !  
plan or enrollee1 a price = a           
prescription drug t exce$s ! price paid 
to ! ph>macy1 exclud+ p5alties or fees  
paid by ph>macies to su* plan1 issu]1 or
 entity4  7#b7 ,default to pass-?r\gh   
pric+  ,= purposes ( p>agraph 7#a71 a   
designat$ plan adm9i/rator ( an         
applicable self-insur$ heal? plan1 or an
 entity provid+ ph>macy b5efit managem5t
 s]vices to su* heal? plan %all n *>ge !
 plan or enrollee an am\nt = a          
presciption drug t exce$s ! price paid  
to ! ph>macy1 exclud+ p5alties paid by  
ph>macies to su* plan or entity1 )\t !  
express p]mission ( ! heal? plan        
sponsor4  7#c7 ,supplem5t>y report+ =   
intra-company prescription drug         
transactions ,a heal? insurance issu] ( 
gr\p heal? insurance cov]age or an      

entity provid+ ph>macy b5efits managem5t
 s]vices "u a gr\p heal? plan or gr\p   
heal? insurance cov]age t conducts      
transactions ) a :olly or p>tially own$ 
ph>macy1 z describ$ 9 p>agraph 7#b71    
%all submit1 toge!r ) ! report "u       
subsection 7b71 a supplem5t>y qu>t]ly   
report to ! plan sponsor t includes--   
7,a7 an explanation ( any b5efit design 
p>amet]s t enc\rage enrollees 9 ! plan  
or cov]age to fill prescriptions at mail
 ord]1 specialty1 or retail ph>macies t 
are :olly or p>tially own$ by t issu] or
 entity2  7,b7 ! p]c5tage ( total       
prescriptions *>g$ to ! plan1 cov]age1  
or enrollees 9 ! plan or cov]age1 t 7   
disp5s$ by mail ord]1 specialty1 or     
retail ph>macies t are :olly or p>tially
 own$ by ! issu] or entity provid+      
ph>macy b5efits managem5t s]vices2 &    
7,c7 a li/ ( all drugs disp5s$ by su*   
:olly or p>tially own$ ph>macy & *>g$ to
 ! plan or cov]age1 or enrollees ( !    
plan or cov]age1 dur+ ! applicable      
qu>t]1 &1 ) respect to ea* drug--  7i7 !

 am\nt *>g$ p] dosage unit or c\rse (   
treatm5t ) respect to enrollees 9 ! plan
 or cov]age1 includ+ am\nts *>g$ to !   
plan or cov]age & am\nts *>g$ to !      
enrollee2  7ii7 ! m$ian am\nt *>g$ to ! 
plan or cov]age1 p] dosage unit or c\rse
 ( treatm5t1 & includ+ am\nts paid by ! 
enrollee1 :5 ! same drug is disp5s$ by  
o!r ph>macies t are n :olly or p>tially 
own$ by ! issu] or entity & t are       
includ$ 9 ! ph>macy network ( t plan or 
cov]age2  7iii7 ! int]qu>tile range ( ! 
co/s1 p] dosage unit or c\rse (         
treatm5t1 & includ+ am\nts paid by !    
enrollee1 :5 ! same drug is disp5s$ by  
o!r ph>macies t are n :olly or p>tially 
own$ by ! issu] or entity & t are       
includ$ 9 ! ph>macy network ( t plan or 
cov]age2 &  7iv7 ! l[e/ co/ p] dosage   
unit or c\rse ( treatm5t1 = su* drug1   
includ+ am\nts *>g$ to ! plan or issu] &
 enrollee1 t is available f any ph>macy 
includ$ 9 ! network ( ! plan or cov]age4
  7d7 ,full rebate pass-,?r\gh to plan  
7#a7 ,9 g5]al ,a ph>macy b5efits manag]1

 a ?ird-p>ty adm9i/rator ( a gr\p heal? 
plan1 a heal? insurance issu] (f]+ gr\p 
heal? insurance cov]age1 or an entity   
provid+ ph>macy b5efits managem5t       
s]vices "u su* heal? plan or heal?      
insurance cov]age %all remit #ajj p]c5t 
( rebates1 fees1 alt]native disc\nts1 & 
all o!r remun]ation receiv$ f a         
ph>maceutical manufactur]1 di/ributor or
 any o!r ?ird p>ty1 t are relat$ to     
utilization ( drugs "u su* heal? plan or
 heal? insurance cov]age1 to ! heal?    
plan issu]4  7#b7 ,=m & mann] (         
remittance ,su* rebates1 fees1          
alt]native disc\nts1 & o!r remun]ation  
%all be-- 7,a7 remitt$ to ! gr\p heal?  
plan 9 a timely fa%ion aft] ! p]iod =   
:i* su* rebates1 fees1 or o!r           
remun]ation is calculat$1 & 9 no case   
lat] ?an #abj days aft] ! end ( su*     
p]iod2  7,b7 fully disclos$ & enum]at$  
to ! gr\p heal? plan sponsor1 z describ$
 9 7b77#a72  7,c7 available = audit by !
 plan sponsor1 or a ?ird p>ty designat$ 
by a plan sponsor no less ?an once p]   

plan ye>2 &  7,d7 return$ to ! issu] or 
entity provid+ ph>maceutical b5efit     
managem5t s]vices by ! gr\p heal? plan  
if audits by su* issu] or entity        
indicate t ! am\nts receiv$ are         
incorrect aft] su* am\nts h be5 paid to 
! gr\p heal? plan4  7#c7 ,audit ( rebate
 contracts ,a ph>macy b5efits manag]1 a 
?ird-p>ty adm9i/rator ( a gr\p heal?    
plan1 a heal? insurance issu] (f]+ a    
gr\p heal? insurance cov]age1 or an     
entity provid+ ph>macy b5efits managem5t
 s]vices "u su* heal? plan or heal?     
insurance cov]age %all make rebate      
contracts ) drug manufactur]s available 
= audit by su* plan sponsor or designat$
 ?ird p>ty1 subject to confid5tiality   
agreem5ts to prev5t re-disclosure ( su* 
contracts4  7e7 ,en=cem5t  7#a7 ,9 g5]al
 ,! ,secret>y1 9 consultation ) !       
,secret>y ( ,labor & ! ,secret>y ( !    
,treasury1 %all en=ce ?is section4  7#b7
 ,failure ,to provide timely in=mation  
,a heal? insurance issu] or an entity   
provid+ ph>macy b5efit managem5t s]vices

 t violates subsection 7a71 fails to    
provide in=mation requir$ "u subsection 
7b71 engages 9 spread pric+ z def9$ 9   
subsection 7c71 or fails to comply ) !  
requirem5ts ( subsection 7d71 or a drug 
manufactur] t fails to provide in=mation
 "u subsection 7b77#a77;,a71 9 a timely 
mann] %all be subject to a civil monet>y
 p5alty 9 ! am\nt ( #aj1jjj = ea* day   
dur+ :i* su* violation cont9ues or su*  
in=mation is n disclos$ or report$4     
7#c7 ,false in=mation ,a heal? insurance
 issu]1 entity provid+ ph>macy b5efit   
managem5t s]vices1 or drug manufactur] t
 kn[+ly provides false in=mation "u ?is 
section %all be subject to a civil money
 p5alty 9 an am\nt n to exce$ #ajj1jjj =
 ea* item ( false in=mation4 ,su* civil 
money p5alty %all be 9 addition to o!r  
p5alties z may be prescrib$ by law4     
7#d7 ,proc$ure ,! provisions ( section  
#aabh;,a ( ! ,social ,security ,act1 o!r
 ?an subsections 7a7 & 7b7 & ! fir/     
s5t5ce ( subsection 7c77#a7 ( su*       
section %all apply to civil monet>y     

p5alties "u ?is subsection 9 ! same     
mann] z su* provisions apply to a p5alty
 or proce$+ "u section #aabh;,a ( !     
,social ,security ,act4  7#e7 ,safe     
h>bor ,! ,secret>y may waive p5alties "u
 p>agraph 7#b71 or ext5d ! p]iod ( "t = 
compliance ) a requirem5t ( ?is section1
 = an entity 9 violation ( ?is section t
 has made a good-fai? ef=t to comply )  
?is section4  7f7 ,rule ( con/ruction   
,no?+ 9 ?is section %all be con/ru$ to  
prohibit entities provid+ ph>macy       
b5efits managem5t s]vices f reta9+ bona 
fide s]vice fees1 provid$ t su* fees are
 transp>5t to gr\p heal? plans & heal?  
insurance issu]s & are n l9k$ directly  
to ! price or =mul>y placem5t or        
position ( a drug4  7g7 ,def9itions ,9  
?is section-- 7#a7 ! t]m simil>ly       
situat$ ph>macy means1 ) respect to a   
p>ticul> ph>macy1 ano!r ph>macy t is    
approximately ! same size 7z measur$ by 
! numb] ( prescription drugs disp5s$71 &
 t s]ves pati5ts 9 ! same geographical  
area1 :e!r ?r\gh physical locations or  

mail ord]2  7#b7 ! t]m :olesale         
acquisition co/ has ! mean+ giv5 su* t]m
 9 section #ahdg;,a7c77#f77;,b7 ( !     
,social ,security ,act2 &  7#c7 ! t]m   
bona fide s]vice fees means fees paid by
 a manufactur]1 cu/om]1 or cli5t 7o!r   
?an a gr\p heal? plan or heal? insurance
 issu]7 ( an entity provid+ ph>macy     
b5efit managem5t s]vices1 to an entity  
provid+ ph>macy b5efit managem5t        
s]vices1 t repres5t fair m>ket value =  
bona fide1 itemiz$ s]vices actually     
p]=m$ on behalf ( ! manufactur]1 cu/om]1
 or cli5t w\ld o!rwise p]=m or contract 
= 9 ! abs5ce ( ! s]vice arrangem5t1 )\t 
prior cons5t = any specific arrangem5ts4
  4  #c4 ,?ird-p>ty adm9i/rators ,any   
obligation on a ?ird-p>ty adm9i/rator "u
 ?is ,act 7includ+ ! am5dm5t made by ?is
 ,act7 %all n affect any o!r direct or  
indirect requirem5t "u any o!r provision
 ( ,f$]al law t applies to ?ird-p>ty    
adm9i/rators (f]+ s]vices to gr\p heal? 
plans4