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HR 6610

Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]

119th Congress Introduced by Robert Aderholt and 36 co-sponsors

To curb PBM costs in FEHBP by standardizing in-network reimbursements at NADAC or wholesale cost plus modest margins and requiring rebates to reduce patient costs.

Introduced in House
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Bill Summary · HR 6610

Summary of HR 6610 (Pharmacists Fight Back )

Jurisdiction: United States Congress (House of Representatives), 119th Congress, 1st Session

Status: Introduced December 11, 2025; referred to the Committee on Oversight and Government Reform

Short Title
- Pharmacists Fight Back

Purpose and intent
- To amend Chapter 89 of Title 5, United States Code, with the objective of limiting costs related to pharmacy benefit managers (PBMs) for Federal employee health benefit plans.
- The bill aims to constrain PBM practices, ensure more favorable reimbursement terms for in-network pharmacies, and increase oversight and penalties for noncompliance.

Key provisions and changes

1) Pharmacy payment and reimbursement requirements (Section 8904(c) insertion)
- OPM cannot contract for or approve a Federal employee health benefits plan unless the plan requires PBMs to:
- Reimburse in-network pharmacies for prescription ingredients at:
- The national average drug acquisition cost (NADAC) on the day of adjudication, or the wholesale acquisition cost if NADAC is unavailable.
- The lesser of 4% of the NADAC (or NADAC-equivalent) or $50.
- Pay an in-network dispensing fee equal to the professional dispensing fee paid by the State under Title XIX (Medicaid) for dispensing a prescription.
- At the point of sale, apply rebates received from manufacturers to reduce coinsurance or copayment owed by the patient, and remit to the health plan carrier the rebate amount minus the reduced patient coinsurance/copayment.

  • Prohibitions on PBMs (and affiliates):

    • Must not direct or steer beneficiaries to specific pharmacies (including affiliate pharmacies) for filling prescriptions.
    • Must not advertise or promote a specific in-network pharmacy over others.
    • Must not create network or credentialing standards, day-supply limits, or delivery method limitations that exclude in-network pharmacies or restrict their ability to fill eligible prescriptions.
    • Must not influence manufacturers to limit distribution to a small number of pharmacies or to non-affiliate pharmacies.
    • Must not require enrollees to reimburse PBMs for dispensing fees paid to in-network pharmacies, or otherwise increase patient cost.

  • Prohibition on post-claim adjustments:

    • PBMs cannot lower or impose additional fees at claim adjudication that reduce reimbursement to pharmacies for prescriptions, or charge fees not associated with the claim.

  • Carrier cooperation:

    • Carriers must cooperate with inspections by OPM (under section 8902b(a)(3)(B)) and provide documents, personnel, and facilities as needed.

2) Definitions (Section 8904(c) and clarifications)
- Affiliate: Includes entities related to PBMs that own/control or are owned/controlled by PBMs, including pharmacies.
- Beneficiary: Person receiving prescription drug benefits.
- In-network pharmacy: State-licensed pharmacy in the same state, participating in the plan, not barred.
- Pharmacy benefits manager (PBM): Entity that manages pharmacy benefits, including processing and payment of prescription drug claims and related functions.
- Prescription drug: Drug covered by a health benefits plan dispensed for self-administration.
- Pharmacy benefits management services: Administration and processing of prescription drug benefits, including adjudication and grievance handling.

3) New sanctions and enforcement (Section 8902b)
- Monetary penalties:
- PBMs may face civil penalties of $10,000 per violation, with caps (up to $100,000 over 10 years for violations related to a given carrier; and up to $50,000 per 10-year period for the carrier overall).
- If a PBM accrues 5 or more penalties against a carrier in a 10-year window, the carrier may be subject to a remediation plan and potential OPM inspection to ensure compliance.

  • Penalty caps and carrier limits:

    • Maximum penalties for a PBM: $100,000 in a 10-year period across all health benefit plans provided by that carrier.
    • Maximum penalties for a carrier: $50,000 in a 10-year period.

  • Remediation plan and oversight:

    • After the fifth penalty within a 10-year period, carriers must develop and submit a remediation plan to ensure PBMs comply with 8904(c) requirements.
    • OPM must inspect carriers to assess compliance with the remediation plan, with ongoing oversight as determined.

  • Debarment:

    • A PBM can be debarred from administering prescription drug benefits if 10 or more civil penalties are imposed on the PBM within a 10-year period.
    • Debarment becomes effective 90 days after the first penalty triggers the debarment, subject to exceptions on appeal.
    • Debarment prohibits payments to or from the debarred PBM under contracts; subcontracts must include necessary provisions to enforce this.
    • Debarment ends if all penalties are overturned or wholly set aside on appeal or if the penalty base is defeated on appeal.

  • Hearing and appellate process:

    • Adverse determinations require reasonable notice and an opportunity for a hearing.
    • Final decisions are subject to judicial review in U.S. District Court for DC or the district where the PBM/carrier resides or has its principal place of business.
    • Appeals standard: substantial evidence and abuse of discretion considerations; due process protections and an orderly transcript record.

4) Conforming amendments and effective date
- Congress would modify related provisions (e.g., 8903a(b)) to reflect the new 8904(c) requirements.
- Effective date: Provisions take effect one year after enactment.

Potential impact

  • Pricing and reimbursement: Aims to curb PBM-imposed costs by standardizing reimbursement at NADAC or wholesale cost plus modest margins, aligning dispensing fees with Medicaid, and ensuring rebates lower patient cost rather than PBM profits.
  • Patient cost impact: Potential reduction in patient coinsurance/copay when rebates are applied, subject to plan design and implementation.
  • Provider access: Enhanced protections against steering or network restrictions that could impede patient access to in-network pharmacies.
  • Oversight and accountability: Introduces penalties and potential debarment for PBMs and carriers, increasing regulatory scrutiny and enforcement capabilities within FEHBP.
  • Administrative burden: Carriers and PBMs may face new compliance, reporting, and audit requirements, along with remediation plans and oversight activities.

Notes
- The bill is authored by a broad group of sponsors and co-sponsors from diverse political backgrounds, indicating bipartisan or cross-aisle interest in PBM reform within federal employee health programs.
- As introduced, the bill would take effect one year after enactment, allowing time for implementation and adjustments by agencies and PBMs.

Compiled from official sources — confirm details with the bill’s official record.

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