H.R. 5197

119 HR 5197 IH: Protect Beneficiaries from Middlemen Act
 U.S. House of Representatives
 2025-09-08
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 I  119th CONGRESS  1st Session  H. R. 5197  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.
1.
Short title
This Act may be cited as the   Protect Beneficiaries from Middlemen Act  .
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.