,i #aai? ,,congress #a/ ,session ,h4 ,r4 #ffaj ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,decemb] #aa1 #bjbe,mr4 ,au*9closs 7= himself1 ,mr4 ,com]1 ,mrs4 ,h>%b>g]1 ,mr4 ,c>t] ( ,georgia1 ,mr4 ,ciscomani1 ,mr4 ,m\lton1 ,mr4 ,deluzio1 ,ms4 ,tlaib1 ,ms4 ,budz9ski1 ,mr4 ,kri%namoor?i1 ,mr4 ,khanna1 ,mr4 ,coh51 ,ms4 ,pressley1 ,mr4 ,vic5te ,gonzalez ( ,texas1 ,mr4 ,moore ( ,alabama1 ,mr4 ,subramanyam1 ,mr4 ,pocan1 ,mr4 ,bi%op1 & ,ms4 ,mc,collum7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,ov]sight & ,gov]nm5t ,re=m ,a ,,bill ,to am5d *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 to limit ! co/s ( ph>macy b5efit manag]s ) respect to ,f$]al employee heal? b5efit plans1 & = o!r purposes4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,ph>maci/s ,fight ,back 9 ,f$]al ,employee ,heal? ,b5efit ,plans ,act4 #b4 ,ph>macy paym5t & reimbursem5t requirem5ts 7a7 ,9 g5]al ,section #hijd ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new subsection3 7c7 7#a7 ,! ,(fice ( ,p]sonnel ,managem5t may n contract = or approve a heal? b5efits plan "u section #hijc ( ?is title unless su* plan-- 7,a7 requires any ph>macy b5efits manag] adm9i/]+ prescription drug b5efits on behalf ( su* heal? b5efits plan1 ei!r directly or ?r\gh an affiliate ( su* ph>macy b5efits manag]1 to-- 7i7 reimburse an 9-network ph>macy = ! +r$i5t co/ ( a prescription drug 9 an am\nt equal to ! sum (-- 7,i7 ! national av]age drug acquisition co/ = ! drug on ! day ( claim adjudication 7or1 9 ! case ( a drug t does n appe> on ! national av]age drug acquisition co/ index1 ! :olesale acquisition co/ = su* prescription drug72 & 7,,ii7 ! less] ( ! am\nt t is equal to #d p]c5t ( ! am\nt describ$ 9 subclause 7,i7 or #ej2 7ii7 pay an 9-network ph>macy a pr(essional disp5s+ fee t is equal to ! pr(essional disp5s+ fee paid by ! ,/ate 9 :i* ! ph>macy is locat$ "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 = disp5s+ a prescription drug2 & 7iii7 = any manufactur] rebate su* ph>macy b5efits manag] or affiliate !re( receives 9 connection ) a drug obta9$ at an 9-network ph>macy by an individual pursuant to su* prescription drug b5efits1 su* ph>macy b5efits manag] or affiliate %all-- 7,i7 apply1 at ! po9t ( sale ( su* drug1 a r$uction to ! am\nt ( any co9surance or copaym5t ow$ by su* individual ) respect to su* drug1 su* t ! am\nt ( co9surance or copaym5t s ow$ is calculat$ bas$ on ! net co/ ( ! drug1 includ+ su* rebate2 & 7,,ii7 remit to ! c>ri] = su* heal? b5efits plan an am\nt equal to ! am\nt ( su* rebate1 less ! am\nt by :i* ! co9surance or copaym5t ow$ by su* individual ) respect to su* drug 0 r$uc$ "u subclause 7,i72 7,b7 prohibits su* ph>macy b5efits manag] & any affiliate !re( f-- 7i7 direct+1 ord]+1 or requir+ an individual enroll$ 9 su* heal? b5efits plan to use a specific ph>macy1 includ+ a ph>macy t is an affiliate ( su* ph>macy b5efits manag]1 = ! purpose ( fill+ a prescription = a prescription drug or receiv+ s]vices2 7ii7 adv]tis+1 m>ket+1 or promot+ a specific ph>macy1 includ+ a ph>macy t is an affiliate ( su* ph>macy b5efits manag]1 ov] ano!r 9-network ph>macy2 7iii7 creat+ any network or engag+ 9 any practice1 includ+ accr$itation or cr$5tial+ /&>ds1 day supply limitations1 or deliv]y me?od limitations1 t excludes an 9-network ph>macy or re/ricts an 9-network ph>macy f fill+ a prescription = a prescription drug = :i* b5efits are available "u su* heal? b5efits plan2 7iv7 directly or indirectly engag+ 9 any practice t attempts to influ5ce or induce a ph>maceutical manufactur] to limit ! di/ribution ( a prescription drug to a small numb] ( ph>macies or c]ta9 types ( ph>macies1 or to re/rict di/ribution ( su* drug to non-affiliate ph>macies2 or 7v7 requir+ an individual enroll$ 9 su* heal? b5efits plan to reimburse ! ph>macy b5efits manag] or affiliate = ! disp5s+ fee paid to an 9-network ph>macy pursuant to subp>agraph 7,a77ii7 ) respect to a prescription drug obta9$ at su* ph>macy by su* individual1 or o!rwise increas+ ! am\nt ow$ by su* individual ) respect to su* drug to acc\nt = su* disp5s+ fee2 7,c7 prohibits any su* ph>macy b5efits manag] f l[]+1 impos+ a fee on1 or o!rwise make any adju/m5t to a prescription drug claim at ! "t ! claim = su* drug is adjudicat$ or aft] ! claim is adjudicat$ t r$uces ! am\nt a ph>macy is reimburs$ = su* drug pursuant to subp>agraph 7,a71 includ+ by *>g+ any fee to su* ph>macy t is n associat$ ) a prescription drug claim2 & 7,d7 requires ! c>ri] provid+ su* heal? b5efits plan to coop]ate ) any inspection ( su* c>ri] c>ri$ out "u section #hijb;b7a77#c77;,b7 ( ?is title1 includ+ by mak+ available to ! ,(fice su* docum5ts1 p]sonnel1 & facilities ( ! c>ri] z & :5 det]m9$ necess>y to ,(fice to c>ry out su* inspection4 7#b7 ,9 ?is subsection3 7,a7 ,! t]m affiliate means an entity1 includ+ a ph>macy1 t directly or indirectly ?r\gh "o or m int]m$i>ies-- 7i7 owns1 9 :ole or 9 "p1 or controls a ph>macy b5efits manag]2 7ii7 is own$1 9 :ole or 9 "p1 or controll$ by t is a ph>macy b5efits manag]2 or 7iii7 is a subsidi>y ( or own$1 9 :ole or 9 "p1 or controll$ by an entity t owns or controls a ph>macy b5efits manag]4 7,b7 ,! t]m b5efici>y means a p]son :o receives prescription drug b5efits "u a heal? b5efits plan4 7,c7 ,! t]m 9-network ph>macy means a ph>macy t is lic5s$ by ! ,/ate bo>d ( ph>macy 9 ! ,/ate 9 :i* su* ph>macy is locat$1 t fills or seeks to fill a prescription = a prescription drug = a b5efici>y1 & is n b>r$ f p>ticipat+ 9 ! program "u ?is *apt] "u section #hijb;a4 7,d7 ,! t]m ph>macy b5efits manag] means a p]son1 bus9ess entity1 affiliate1 or o!r entity t p]=ms ph>macy b5efits managem5t s]vices4 7,e7 ,! t]m ph>macy b5efits managem5t s]vices-- 7i7 means ! manag+ or adm9i/ration ( a plan or program t pays =1 reimburses1 & cov]s ! co/ ( prescription drugs & m$ical devices2 & 7ii7 includes ! process+ & paym5t ( claims = prescription drugs & ! adjudication ( appeals or grievances relat$ to ! prescription drug b5efit4 7,f7 ,! t]m prescription drug means a prescription drug cov]$ by a heal? b5efits plan t is disp5s$ to a b5efici>y = self-adm9i/ration4 4 7b7 ,noncompliance p5alties 7#a7 ,9 g5]al ,*apt] #hi ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by ins]t+ aft] section #hijb;a ! foll[+ new section3 #hijb;b4 ,ph>macy b5efit manag]-relat$ sanctions 7a7 ,monet>y p5alties 7#a7 ,9 g5]al ,except z o!rwise provid$ by ?is subsection & subsection 7c71 if ! ,(fice ( ,p]sonnel ,managem5t det]m9es t a ph>macy b5efits manag] violat$ a requirem5t or prohibition applicable to su* ph>macy b5efits manag] ) respect to a heal? b5efits plan pursuant to section #hijd7;c77#a7 ( ?is title1 ! ,(fice %all1 9 addition to any o!r p5alties t may be prescrib$ by law & aft] consultation ) ! ,attorney ,g5]al1 impose a civil monet>y p5alty ( #aj1jjj = ea* su* violation-- 7,a7 on su* ph>macy b5efits manag]2 & 7,b7 if1 dur+ ! #aj-ye> p]iod end+ on ! imposition ( su* civil monet>y p5alty1 n few] ?an five civil monet>y p5alties h be5 impos$ on su* ph>macy b5efits manag] "u ?is p>agraph ) respect to heal? b5efit plans provid$ by ! c>ri] provid+ su* heal? b5efits plan1 on su* c>ri]4 7#b7 ,maximum p5alty am\nt 7,a7 ,ph>macy b5efit manag]s ,= ea* c>ri] provid+ a heal? b5efits plan ) respect to :i* a ph>macy b5efits manag] is det]m9$ to h committ$ a violation describ$ 9 p>agraph 7#a71 ! total am\nt ( civil monet>y p5alties impos$ on su* ph>macy b5efits manag] "u su* p>agraph = violations ) respect to ! heal? b5efit plans ( su* c>ri] _m n exce$ #ajj1jjj dur+ any #aj-ye> p]iod4 7,b7 ,c>ri]s ,! total am\nt ( civil monet>y p5alties impos$ on a c>ri] "u p>agraph 7#a7 may n exce$ #ej1jjj dur+ any #aj-ye> p]iod4 7#c7 ,rem$iation plan 7,a7 ,9 g5]al ,n lat] ?an #fj days aft] ! date on :i* ! ,(fice ( ,p]sonnel ,managem5t imposes a civil monet>y p5alty on a c>ri] "u p>agraph 7#a7 ) respect to a ph>macy b5efits manag] t is ! fif? su* civil monet>y p5alty impos$ on su* c>ri] ) respect to su* ph>macy b5efits manag] 9 a #aj-ye> p]iod1 su* c>ri] %all develop & submit to ! ,(fice ( ,p]sonnel ,managem5t a plan to ensure t ea* ph>macy b5efit manag] adm9i/]+ prescription drug b5efits on behalf ( a heal? b5efits plan provid$ by su* c>ri] complies ) ! requirem5ts & prohibitions applicable to su* ph>macy b5efit manag] pursuant to section #hijd7;c77#a74 7,b7 ,ov]sight ,n lat] ?an #fj days aft] ! date on :i* a c>ri] submits plan "u subp>agraph 7,a71 & ) su* frequ5cy !reaft] z det]m9$ appropriate by ! ,(fice ( ,p]sonnel ,managem5t1 ! ,(fice ( ,p]sonnel ,managem5t %all inspect su* c>ri] to assess ! compliance ( su* c>ri] ) su* plan4 7#d7 ,sequ5tial imposition ,= ! purposes ( ?is subsection1 any civil monet>y p5alties concurr5tly impos$ "u p>agraph 7#a7 %all be deem$ to be impos$ sequ5tially4 7#e7 ,civil action 7,a7 ,9 g5]al ,a civil action to recov] a civil monet>y p5alty impos$ "u ?is subsection %all be br\ght by ! ,attorney ,g5]al 9 ! "n ( ! ,unit$ ,/ates1 & may be br\ght 9 ! ,unit$ ,/ates di/rict c\rt = ! di/rict :]e ! claim involv$ 0 pres5t$ or :]e ! ph>macy b5efits manag] or c>ri] subject to su* civil monet>y p5alty resides4 7,b7 ,treatm5t ( am\nts recov]$ ,am\nts recov]$ "u ?is subsection %all be paid to ! ,(fice ( ,p]sonnel ,managem5t = deposit into ! ,employees ,heal? ,b5efits ,fund4 7#f7 ,d$uction f am\nts ow$ ,! am\nt ( a civil monet>y p5alty impos$ "u ?is subsection may be d$uct$ f any sum !n or lat] ow+ by ! ,unit$ ,/ates to ! p>ty aga9/ :om ! p5alty or assessm5t has be5 levi$4 7#g7 ,/atute ( limitations ,! ,(fice ( ,p]sonnel ,managem5t may n initiate any action to impose a civil monet>y p5alty on a ph>macy b5efits manag] or c>ri] "u ?is subsection lat] ?an #f ye>s aft] ! date ( ! violation ( ! requirem5t or prohibition by ! ph>macy b5efits manag] = :i* su* civil monet>y p5alty w\ld be impos$4 7b7 ,deb>m5t 7#a7 ,9 g5]al ,! ,(fice ( ,p]sonnel ,managem5t %all b> a ph>macy b5efits manag] f adm9i/]+ prescription drug b5efits on behalf ( a heal? b5efits plan1 ei!r directly ( ?r\gh an affiliate ( su* ph>macy b5efits manag]1 "u ! program "u ?is *apt] if1 9 any #aj-ye> p]iod1 ! ,(fice ( ,p]sonnel ,managem5t imposes #aj or m civil monet>y p5alties on su* ph>macy b5efits manag] "u subsection 7a74 7#b7 ,effective date ,except z provid$ by subsection 7c71 deb>m5t ( a ph>macy b5efits manag] "u p>agraph 7#a7 %all be effective on ! date t is #ij days aft] ! date on :i* ! ,(fice ( ,p]sonnel ,managem5t imposes ! fir/ civil monet>y p5alty pursuant to :i* su* ph>macy b5efits manag] is subject to su* deb>m5t4 7#c7 ,paym5t prohibit$ 7,a7 ,9 g5]al ,not)/&+ section #hijb7;j7 or any o!r provision ( ?is *apt]1 if1 "u ?is section a ph>macy b5efits manag] is deb>r$ "u p>agraph 7#a71 no paym5t may be made by a c>ri] pursuant to any contract "u ?is *apt] 7ei!r to su* ph>macy b5efits manag] or by reimbursem5t7 = any s]vice or supply furni%$ by su* ph>macy b5efits manag] dur+ ! p]iod ( ! deb>m5t4 7,b7 ,subcontract contracts ,ea* contract "u ?is *apt] %all conta9 su* provisions z may be necess>y to c>ry out subp>agraph 7,a7 & ! o!r provisions ( ?is section4 7#d7 ,t]m9ation ,! deb>m5t ( a ph>macy b5efits manag] "u p>agraph 7#a7 %all be imm$iately t]m9at$ if all civil monet>y p5alties pursuant to :i* su* ph>macy b5efits manag] is subject to su* deb>m5t are ov]turn$ or :olly set aside on appeal4 7#e7 ,rule ( con/ruction ,= ! purposes ( ?is subsection1 a civil monet>y p5alty is a civil monet>y p5alty pursuant to :i* a ph>macy b5efits manag] is subject to deb>m5t "u p>agraph 7#a7 if su* civil monet>y p5alty is n less ?an ! t5? civil monet>y p5alty impos$ on su* ph>macy b5efits manag] "u subsection 7a7 dur+ a #aj-ye> p]iod t-- 7,a7 has n be5 appeal$ & = :i* ! p]iod ( appeal has elaps$2 or 7,b7 has be5 appeal$1 all appeals h be5 exhau/$1 & has n be ov]turn$ or :olly set aside4 7c7 ,he>+ 7#a7 ,9 g5]al ,! ,(fice ( ,p]sonnel ,managem5t %all n make a det]m9ation adv]se to a ph>macy b5efits manag] or c>ri] "u subsection 7a7 or a det]m9ation adv]se to a ph>macy b5efits manag] 7b7 until su* ph>macy b5efits manag] or c>ri]1 z applicable1 has be5 giv5 reasonable notice & an opportunity = ! det]m9ation to be made aft] a he>+ z provid$ 9 accordance ) ?is subsection4 7#b7 ,he>+ requir$ ,any ph>macy b5efits manag] or c>ri] t is ! subject ( an adv]se det]m9ation by ! ,(fice ( ,p]sonnel ,managem5t "u ?is section %all be entitl$ to reasonable notice & an opportunity to reque/ a he>+ on ! record1 & to judicial review z provid$ 9 ?is subsection aft] ! ,(fice ( ,p]sonnel ,managem5t makes a f9al decision reg>d+ su* adv]se det]m9ation4 7#c7 ,he>+ crit]ia ,! ,(fice ( ,p]sonnel ,managem5t %all grant a reque/ = a he>+ "u p>agraph 7#b7 ^u a %[+ t due process rights h n previ\sly be5 af=d$ ) respect to any f9d+ ( fact :i* is reli$ ^u z a cause = an adv]se det]m9ation "u ?is section4 ,su* he>+ %all be conduct$ )\t reg>d to sub*apt] ,,ii ( *apt] #e & *apt] #g ( ?is title by a he>+ (fic] :o %all be designat$ by ! ,director ( ! ,(fice ( ,p]sonnel ,managem5t & :o %all n o!rwise h be5 involv$ 9 ! adv]se det]m9ation be+ appeal$4 7#d7 ,reque/ = he>+ ,a reque/ = a he>+ "u p>agraph 7#b7 %all be fil$ )9 su* p]iod & 9 accordance ) su* proc$ures z ! ,(fice ( ,p]sonnel ,managem5t %all prescribe by regulation4 7#e7 ,appeal 7,a7 ,9 g5]al ,any ph>macy b5efits manag] or c>ri] adv]sely affect$ by a f9al decision ( ! ,(fice ( ,p]sonnel ,managem5t reg>d+ an adv]se det]m9ation t is made aft] a he>+ "u p>agraph 7#b7 ) respect to su* adv]se det]m9ation & to :i* su* ph>macy b5efits manag] or c>ri] 0 a p>ty may seek review ( su* f9al decision 9 ! ,unit$ ,/ates ,di/rict ,c\rt = ! ,di/rict ( ,columbia or = ! di/rict 9 :i* ! ph>macy b5efits manag] or c>ri] resides or has 8 or h] pr9cipal place ( bus9ess by fil+ a notice ( appeal 9 su* c\rt )9 #fj days aft] ! date ! decision is issu$1 & by simultane\sly s5d+ copies ( su* notice by c]tifi$ mail to ! ,director ( ! ,(fice & to ! ,attorney ,g5]al4 7,b7 ,answ] ,9 answ] to an appeal fil$ "u subp>agraph 7,a71 ! ,director ( ! ,(fice ( ,p]sonnel ,managem5t %all promptly file 9 ! relevant c\rt a c]tifi$ copy ( ! transcript ( ! record ( ! he>+ conduct$ "u p>agraph 7#b7 & o!r evid5ce ^u :i* ! f9d+s & f9al decision compla9$ ( are bas$4 7,c7 ,c\rt au?ority ,) respect to an appeal fil$ "u subp>agraph 7,a71 ! c\rt %all h p[] to ent]1 ^u ! plead+s & evid5ce ( record1 a judgm5t affirm+1 modify+1 or sett+ aside1 9 :ole or 9 "p1 ! f9al decision ( ! ,(fice ( ,p]sonnel ,managem5t t is ! subject ( su* appeal1 ) or )\t rem&+ ! case = a rehe>+4 ,! c\rt %all n set aside or rem& su* f9al decision unless !re is n sub/antial evid5ce on ! record1 tak5 z :ole1 to support ! su* f9al decision or unless ! actions ( ! ,(fice ( ,p]sonnel ,managem5t ) respect to su* f9al decision con/itutes an abuse ( discretion4 7#f7 ,def5se =feiture ,matt]s t 7 rais$ or t c\ld h be5 rais$ 9 a he>+ "u p>agraph 7#b7 or an appeal "u p>agraph 7#e7 may n be rais$ z a def5se to a civil action by ! ,unit$ ,/ates to collect a civil monet>y p5alty impos$ "u subsection 7a74 7d7 ,affiliate2 ph>macy b5efits manag]2 prescription drug def9$ ,9 ?is section1 ! t]ms affiliate1 ph>macy b5efits manag] & prescription drug h ! mean+s giv5 su* t]ms1 respectively1 9 section #hijd7;c7 ( ?is title4 4 7#b7 ,cl]ical am5dm5t ,! table ( sections = *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by ins]t+ aft] ! item relat+ to section #hijb;a ! foll[+ new item3 #hijb;b4 ,ph>macy b5efit manag]-relat$ sanctions4 4 7c7 ,con=m+ am5dm5t ,section #hijc;a7b7 ( title #e1 ,unit$ ,/ates ,code1 is am5d$-- 7#a7 9 p>agraph 7#c71 by /rik+ & at ! end2 7#b7 9 p>agraph 7#d71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#c7 by add+ at ! end ! foll[+ new p>agraph3 7#e7 complies ) ! requirem5ts "u section #hijd7;c74 4 7d7 ,effective date ,! am5dm5ts made by ?is ,act %all take effect on ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is ,act4