119-hr5197

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5197 Introduced in House

    (IH) ]

<DOC>

119th CONGRESS
 1st Session
 H. R. 5197

 To amend title XVIII of the Social Security Act to limit cost sharing 
 for drugs under the Medicare program.

_______________________________________________________________________

 IN THE HOUSE OF REPRESENTATIVES

 September 8, 2025

 Ms. Malliotakis introduced the following bill; which was referred to 
the Committee on Energy and Commerce, and in addition to the Committee 
 on Ways and Means, for a period to be subsequently determined by the 
 Speaker, in each case for consideration of such provisions as fall 
 within the jurisdiction of the committee concerned

_______________________________________________________________________

 A BILL

 To amend title XVIII of the Social Security Act to limit cost sharing 
 for drugs under the Medicare program.

 Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

 This Act may be cited as the ``Protect Beneficiaries from Middlemen 
Act''.

SEC. 2. LIMITATION ON COST SHARING TO NET PRICE AMOUNT UNDER MEDICARE 
 PART D.

    (a) In General.--

Section 1860D-2 of the Social Security Act (42 
U.S.C. 1395w-102) is amended--

    (1) in subsection

    (b) --
        (A) in paragraph

    (2)
        (A) , by striking ``

    (8) and

    (9) '' and inserting ``

    (8) ,

    (9) , and

    (10) '';
        (B) in paragraph

    (9)
        (B)
            (ii) , by striking ``For a 
 plan year'' and inserting ``Subject to paragraph

    (10) , 
 for a plan year''; and
            (C) by adding at the end the following new 
 paragraph:
 ``

    (10) Limitation on cost sharing to net price amount.--
 ``
        (A) In general.--For a plan year beginning on or 
 after January 1, 2027, the coverage provides benefits 
 for a supply of a covered part D drug dispensed by a 
 pharmacy, for costs in excess of the deductible 
 specified in paragraph

    (1) and prior to an individual 
 reaching the out-of-pocket threshold under paragraph

    (4) , with cost-sharing for a month's supply that does 
 not exceed the average net price for such a supply of 
 such drug during such plan year (or, if lower, the 
 applicable cash price for such a supply of such drug so 
 dispensed by such pharmacy).
 ``
        (B) === Definitions. ===
-In this paragraph:
 ``
            (i) Applicable cash price.--The term 
 `applicable cash price' means, with respect to 
 a supply of a covered part D drug dispensed by 
 a pharmacy, the price that such pharmacy would 
 charge for such supply of such drug dispensed 
 to an individual without benefits for such drug 
 under any Federal health care program (as 
 defined in 

section 1128B), a group health plan 
 or group or individual health insurance 
 coverage (as such terms are defined in 

section 2791 of the Public Health Service Act), or the 
 program established under chapter 89 of title 
 5, United States Code.
 ``
            (ii) Average net price.--The term 
 `average net price' means, with respect to a 
 supply of a covered part D drug, a prescription 
 drug plan, and a plan year, the average amount 
 paid under such plan (including any amounts 
 paid by an individual enrolled under such plan 
 as cost sharing for such drug) as payment for 
 such a supply of such drug dispensed during 
 such year, less any rebates or other forms of 
 remuneration received under such plan with 
 respect to such drug.''; and

    (2) in subsection
            (c) , by adding at the end the following 
 new paragraph:
 ``

    (7) Cost sharing limited to net price.--The coverage is 
 provided in accordance with subsection

    (b)

    (10) .''.

    (b) Conforming Amendment to Cost-Sharing for Low-Income 
Individuals.--

Section 1860D-14

    (a)

    (1)
            (D) 
            (iii) of the Social Security Act 
(42 U.S.C. 1395w-114

    (a)

    (1)
            (D) 
            (iii) ) is amended by adding at the end the 
following new sentence: ``For plan year 2027 and subsequent plan years, 
the copayment amount applicable under this clause to a supply of a 
covered part D drug dispensed to the individual may not exceed the 
amount provided under 

section 1860D-2

    (b)

    (10) .''.
            (c) GAO Report.--Not later than January 1, 2029, the Comptroller 
General of the United States shall submit to Congress a report 
containing--

    (1) an analysis of compliance with the amendments made by 
 this section;

    (2) an analysis of enforcement of such amendments;

    (3) recommendations with respect to improving such 
 enforcement; and

    (4) recommendations relating to improving public 
 disclosure, and public awareness of, the requirements of such 
 amendments.
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