,,ii #aafth ,,congress #ast ,session ,s4 #fdj ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,march #d1 #bjai,mr4 ,kennedy introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to require pharmacy-negotiated price concessions to be included in negotiated prices at the point-of-sale under part ,d of the ,medicare program1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,phair ,pricing ,act of #bjai4 #b4 ,requiring pharmacy-negotiated price concessions and pharmacy incentive payments and adjustments to be included in negotiated prices at the point-of-sale under part ,d of the ,medicare program ,section #ahfj;,d-#b7;d77#a77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7;d77#a77;,b77 is amended-- 7#a7 by striking prices4--,for purposes and inserting 8prices4-- 7i7 ,in general ,for purposes 2 and 7#b7 by adding at the end the following new clauses3 7ii7 ,prices negotiated with pharmacy at point-of-sale 7,i7 ,in general ,subject to subclause 7,,iii71 for plan years beginning on or after ,january #a1 #bjbj1 negotiated prices for covered part ,d drugs described in clause 7i7 provided under a prescription drug plan1 including all contingent and noncontingent concessions1 adjustments1 payments1 and fees 7including dispensing fees7 negotiated with the pharmacy dispensing such drug1 shall be provided at the point-of-sale of such drug4 ,such negotiated price shall not include any incentive payments and adjustments or any other contingent concessions1 adjustments1 payments1 or fees that increase the amount of such negotiated price4 7,,ii7 ,application of pharmacy incentive payments and adjustments 7aa7 ,in general ,for plan years beginning on or after ,january #a1 #bjbj1 a ,,pdp sponsor-- 7,,aa7 shall apply a system under which incentive payments and adjustments using only quality measures established by the ,secretary under item 7bb7 are made to a pharmacy with respect to payment for covered part ,d drugs dispensed by such pharmacy2 and 7,,bb7 may not apply any other incentive payments and adjustments with respect to such payment outside of such system4 ,application of such system may not result in a decrease in reimbursement to such pharmacy for such drug after the point-of-sale of such drug4 7bb7 ,standard pharmacy quality measures ,the ,secretary shall establish standard quality measures that may be used in a system described in item 7aa74 ,such measures shall be-- 7,,aa7 focused on improving patient health outcomes2 7,,bb7 standardized across ,,pdp sponsors2 7,,cc7 pharmacy-specific in application2 7,,dd7 relevant to the type of pharmacy concerned 7such as specialty pharmacies71 taking into account the items and services furnished by the pharmacy and the patient population served by the pharmacy2 7,,ee7 applied only when relevant to the specific drug 7or drug class of such drug7 being furnished by the pharmacy or when relevant to management of the condition for which such drug has been prescribed2 and 7,,ff7 based on achievable and proven criteria measuring pharmacy performance over which the pharmacy has meaningful control and ability to influence4 ,in establishing such standards1 the ,secretary shall consult with stakeholders1 including ,,pdp sponsors and ,,ma organizations1 pharmacies across pharmacy practice types1 pharmacy benefit managers1 patient advocacy organizations1 drug manufacturers1 appropriate standard-setting organizations1 and other entities determined appropriate by the ,secretary4 7,,iii7 ,no increase in cost sharing ,subclause 7,i7 shall not apply in the case where application of such subclause would increase the amount owed by an individual in cost sharing above the amount such individual would have owed in cost sharing without application of such subclause4 7,,iv7 ,discrepancies between negotiated prices and actual reimbursement ,in the case that the ,secretary determines that the negotiated price of a ,,pdp sponsor applied at the point-of-sale with respect to a covered part ,d drug for a year dispensed by a pharmacy was greater than the total reimbursement made to such pharmacy for such drug for such year1 such sponsor shall1 not later than #ij days after receiving notice of such determination1 furnish to the pharmacy that dispensed such drug and to the ,secretary a written explanation of why such negotiated price was greater than such reimbursement4 7,v7 ,specialty pharmacy ,for purposes of carrying out this clause 7including subclause 7,,ii77bb77,,dd771 the ,secretary shall1 not later than ,december #ca1 #bjai1 define the term specialty pharmacy in consultation with relevant stakeholders4 7,,vi7 ,definitions ,in this clause3 7aa7 ,incentive payments and adjustments ,the term incentive payments and adjustments means1 with respect to payment to a pharmacy by a ,,pdp sponsor for a covered part ,d drug1 any prospective or retrospective price concessions1 rebates1 discounts1 fees1 reconciliation adjustments1 bonuses1 performance payments1 incentives1 and any other adjustment to such payment determined through the use of a quality measure1 regardless of when such payments and adjustments are applied4 ,such term does not include any manufacturer rebates or concessions made with respect to such drug4 7bb7 ,quality measure ,the term quality measure means performance criteria used by a ,,pdp sponsor 7including an entity that contracts with such sponsor1 such as a pharmacy benefit manager7 to determine the amount or applicability of incentive payments and adjustments4 7cc7 ,,pdp sponsor ,the term ,,pdp sponsor includes an ,,ma organization offering an ,,ma-,,pd plan under part ,c and an entity that contracts with such sponsor or organization1 such as a pharmacy benefit manager4 7iii7 ,reasonable reimbursement requirement ,in no case may a negotiated price 7as described in clause 7ii77,i77 for a covered part ,d drug furnished by a pharmacy during a plan year beginning on or after ,january #a1 #bjbj1 be less than such pharmacy's cost of purchasing and dispensing such drug and providing such other services associated with furnishing such drug as may be specified by the ,secretary4 7iv7 ,claim reimbursement disclosure requirements ,with respect to payment made by a ,,pdp sponsor to a pharmacy for a covered part ,d drug furnished by such pharmacy during a plan year beginning on or after ,january #a1 #bjbj1 such sponsor shall promptly furnish all pricing components including the ,network ,reimbursement ,,id used to price the claim1 any fees1 pharmacy price concessions1 discounts1 incentives or any other forms of remuneration that affect payment and pricing of the claim as part of the claim adjudication response at the point-of-sale4 ,all aforementioned items1 including ,network ,reimbursement ,,id1 fees1 pharmacy price concessions1 discounts1 incentives1 or any other forms of remuneration that affect payment and pricing of the claim shall each be identified in a predetermined line item in the remittance advice that is standard across the industry4 ,the ,part ,d sponsor shall include suitable claim-level detail on the electronic remittance advice that accompanies each payment4 ,this claim-level detail shall include1 in an industry standardized format1 all fields needed to properly identify the claim1 including the ,claim ,authorization ,number1 date of service1 date of payment remittance1 ingredient cost reimbursed1 dispensing fee reimbursed1 payment amounts including the ,network ,,id used to price the claim1 the specific dollar amounts and the appropriate qualifier codes for each payment adjustment including fees1 pharmacy price concessions1 or incentives4 7v7 ,violation process ,a ,,pdp sponsor shall participate in any process established by the ,secretary for purposes of determining whether such sponsor has violated a provision of clauses 7ii7 through 7iv74 4 #c4 ,pharmacy benefit manager provision of information 7a7 ,in general ,section #aaej;,a7b77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#bc7;b77#b77 is amended by striking excluding and inserting including4 7b7 ,effective date ,the amendment made by subsection 7a7 shall apply with respect to contract years beginning on or after ,january #a1 #bjbj4