[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4507 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 4507
To amend the Employee Retirement Income Security Act of 1974 to promote
transparency in health coverage and reform pharmacy benefit management
services with respect to group health plans, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 10, 2023
Mr. Good of Virginia (for himself and Mr. DeSaulnier) introduced the
following bill; which was referred to the Committee on Education and
the Workforce, and in addition to the Committees on Energy and
Commerce, and 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 the Employee Retirement Income Security Act of 1974 to promote
transparency in health coverage and reform pharmacy benefit management
services with respect to group health plans, and for other purposes.
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 ``Transparency in Coverage Act of
2023''.
SEC. 2. PROMOTING GROUP HEALTH PLAN AND GROUP HEALTH INSURANCE COVERAGE
PRICE TRANSPARENCY.
(a) In General.--
(1) ERISA.--
(A) In general.--Section 719 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1185h) is amended to read as follows:
``SEC. 719. PRICE TRANSPARENCY REQUIREMENTS.
``(a) In General.--A group health plan, and a health insurance
issuer offering group health insurance coverage, shall make available
to the public accurate and timely disclosures of the following
information:
``(1) Claims payment policies and practices.
``(2) Periodic financial disclosures.
``(3) Data on enrollment.
``(4) Data on disenrollment.
``(5) Data on the number of claims that are denied.
``(6) Data on rating practices.
``(7) Information on cost-sharing and payments with respect
to any out-of-network coverage (or with respect to any item and
service furnished under such a plan or such group health
insurance coverage that does not use a network of providers).
``(8) Information on participant and beneficiary rights
under this part.
``(9) Rate and payment information described in subsection
(d).
``(10) Other information as determined appropriate by the
Secretary.
Rate and payment information described in paragraph (9) shall be made
available to the public not later than January 10, 2025, and not later
than the tenth day of every month thereafter, in the manner described
in subsection (d)(2)(A), and, beginning on January 1, 2027, in real-
time through an application program interface (or successor technology)
described in subsection (d)(2)(B).
``(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain language. The
term `plain language' means language that the intended audience,
including individuals with limited English proficiency, can readily
understand and use because that language is clear, concise, well-
organized, accurately describes the information, and follows other best
practices of plain language writing. The Secretary, jointly with the
Secretary of Health and Human Services and the Secretary of Labor,
shall develop and issue standards for plain language writing for
purposes of this section and shall develop a standardized reporting
template and standardized definitions of terms to allow for comparison
across group health plans and health insurance coverage.
``(c) Cost Sharing Transparency.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
shall, upon request of a participant or beneficiary and in a
timely manner, provide to the participant or beneficiary a
statement of the amount of cost-sharing (including deductibles,
copayments, and coinsurance) under the participant's or
beneficiary's plan or coverage that the participant or
beneficiary would be responsible for paying with respect to the
furnishing of a specific item or service by a provider. At a
minimum, such information shall include the information
specified in paragraph (2) and shall be made available at no
cost to the participant or beneficiary through a self-service
tool that meets the requirements of paragraph (3) or through a
paper or phone disclosure, at the option of the participant or
beneficiary, that meets such requirements as the Secretary may
specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are available
under a group health plan or group health insurance coverage
(as applicable) furnished by a health care provider to a
participant or beneficiary of such plan or coverage, the
following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate (as defined in subsection (f)) for such item or
service and for any other item or service that is
inherent in the furnishing of the item or service that
is the subject of such request.
``(B) If such provider is not a participating
provider, the allowed amount, percentage of billed
charges, or other rate that such plan or coverage will
recognize as payment for such item or service, along
with a notice that such individual may be liable for
additional charges billed by such provider.
``(C) The estimated amount of cost sharing
(including deductibles, copayments, and coinsurance)
that the participant or beneficiary will incur for such
item or service (which, in the case such item or
service is to be furnished by a provider described in
subparagraph (B), shall be calculated using the amount
or rate described in such subparagraph (or, in the case
such plan or issuer uses a percentage of billed charges
to determined the amount of payment for such provider,
using a reasonable estimate of such percentage of such
charges)).
``(D) The amount the participant or beneficiary has
already accumulated with respect to any deductible or
out of pocket maximum under the plan or coverage
(broken down, in the case separate deductibles or
maximums apply to separate participants and
beneficiaries enrolled in the plan or coverage, by such
separate deductibles or maximums, in addition to any
cumulative deductible or maximum).
``(E) Any shared savings or other benefit available
to the participant or beneficiary with respect to such
item or service.
``(F) In the case such plan or coverage imposes any
frequency or volume limitations with respect to such
item or service (excluding medical necessity
determinations), the amount that such participant or
beneficiary has accrued towards such limitation with
respect to such item or service.
``(G) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan or group health insurance coverage.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan or health
insurance issuer offering group health insurance coverage meets
the requirements of this paragraph if such tool--
``(A) is based on an Internet website, mobile
application, or other platform determined appropriate
by the Secretary;
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information
provided through such tool is accurate at the time such
request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such plan and such
item or service for purposes of facilitating
price comparisons; or
``(iii) a provider that is not described in
clause (ii); and
``(E) provides that such a request may be made with
respect to an item or service through use of the
billing code for such item or service or through use of
a descriptive term for such item or service.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing codes
to a single descriptive term if the Secretary determines that
the billing codes to be so linked correspond to items and
services.
``(4) Provider tool.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
shall permit providers to learn the amount of cost-sharing
(including deductibles, copayments, and coinsurance) that would
apply under an individual's plan or coverage that the
individual would be responsible for paying with respect to the
furnishing of a specific item or service by another provider in
a timely manner upon the request of the provider and with the
consent of such individual in the same manner and to the same
extent as if such request has been made by such individual. As
part of any tool used to facilitate such requests from a
provider, such plan or issuer offering health insurance
coverage may include functionality that--
``(A) allows providers to submit the notifications
to such plan or coverage required under section 2799B-6
of the Public Health Service Act; and
``(B) provides for notifications required under
section 716(f) to such an individual.
``(d) Rate and Payment Information.--
``(1) In general.--For purposes of subsection (a)(9), the
rate and payment information described in this subsection is,
with respect to a group health plan or group health insurance
coverage (as applicable), the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan or coverage, the in-network rate (in a dollar
amount) in effect as of the first day of the plan year
during which such information is submitted with each
provider (identified by national provider identifier)
that is a participating provider with respect to such
item or service (or, in the case such rate is not
available in a dollar amount, such formulae, pricing
methodologies, or other information used to calculate
such rate).
``(B) With respect to each dosage form and
indication of each drug (identified by national drug
code) for which benefits are available under such plan
or coverage--
``(i) the in-network rate (in a dollar
amount) in effect as of the first day of the
plan year during which such information is
submitted with each provider (identified by
national provider identifier) that is a
participating provider with respect to such
drug (or, in the case such rate is not
available in a dollar amount, such formulae,
pricing methodologies, or other information
used to calculate such rate); and
``(ii) the average amount paid by such plan
(net of rebates, discounts, and price
concessions) for such drug dispensed or
administered during the 90-day period beginning
180 days before such date of submission to each
provider that was a participating provider with
respect to such drug, broken down by each such
provider (identified by national provider
identifier), other than such an amount paid to
a provider that, during such period, submitted
fewer than 20 claims for such drug to such plan
or coverage.
``(C) With respect to each item or service for
which benefits are available under such plan or
coverage, the amount billed, and the amount allowed by
the plan or coverage, for each such item or service
furnished during the 90-day period specified in
subparagraph (B) by a provider that was not a
participating provider with respect to such item or
service, broken down by each such provider (identified
by national provider identifier), other than items and
services with respect to which fewer than 20 claims for
such item or service were submitted to such plan or
coverage during such period.
Such rate and payment information shall be made available with
respect to each individual item or service, regardless of
whether such item or service is paid for as part of a bundled
payment, episode of care, value-based payment arrangement, or
otherwise.
``(2) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under subsection (a)(9)
shall be so made available in dollar amounts through 3
separate machine-readable files corresponding to the
information described in each of subparagraphs (A)
through (C) of paragraph (1) that meet such
requirements as specified by the Secretary not later
than 180 days after the date of the enactment of this
paragraph through rulemaking. Such requirements shall
ensure that such files are limited to an appropriate
size, do not include information that is duplicative of
information contained in the same file or in other
files made available under such subsection, are made
available in a widely-available format that allows for
information contained in such files to be compared
across group health plans and group health insurance
coverage, and are accessible to individuals at no cost
and without the need to establish a user account or
provide other credentials.
``(B) Real-time provision of information.--
``(i) In general.--Subject to clause (ii),
beginning January 1, 2026, rate and payment
information required to be made available by a
group health plan or health insurance issuer
under subsection (a)(9) shall, in addition to
being made available in the manner described in
subparagraph (A), be made available through an
application program interface (or successor
technology) that provides access to such
information in real time and that meets such
technical standards as may be specified by the
Secretary.
``(ii) Exemption for certain plans or
coverage.--Clause (i) shall not apply with
respect to information described in such clause
required to be made available by a group health
plan or health insurance issuer offering health
insurance coverage if such plan or coverage, as
applicable, provides benefits for fewer than
500 participants and beneficiaries.
``(3) User guide.--The Secretary, Secretary of Health and
Human Services, and Secretary of the Treasury shall jointly
make available to the public instructions written in plain
language explaining how individuals may search for information
described in paragraph (1) in files submitted in accordance
with paragraph (2).
``(4) Annual summary.--For each year (beginning with 2025),
each group health plan and health insurance issuer offering
group health insurance coverage shall make public a machine-
readable file meeting such standards as established by the
Secretary under paragraph (2) containing a summary of all rate
and payment information made public by such plan or issuer with
respect to such plan or coverage during such year (such as
averages of all such information so made public).
``(e) Attestation.--Each group health plan and health insurance
issuer offering group health insurance coverage shall annually submit
to the Secretary an attestation of such plan's or such coverage's
compliance with the provisions of this section along with a link to
disclosures made in accordance with subsection (a).
``(f) Definitions.--In this subsection:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 716 and
includes a participating facility.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group health insurance
coverage and an item or service furnished by a provider that is
a participating provider with respect to such plan or coverage
and item or service, the contracted rate (reflected as a dollar
amount) in effect between such plan or coverage and such
provider for such item or service.''.
(B) Clerical amendment.--The table of contents in
section 1 of such Act is amended by striking the item
relating to section 719 and inserting the following new
item:
``Sec. 719. Price transparency requirements.''.
(2) IRC.--
(A) In general.--Section 9819 of the Internal
Revenue Code of 1986 is amended to read as follows:
``SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS.
``(a) In General.--A group health plan shall make available to the
public accurate and timely disclosures of the following information:
``(1) Claims payment policies and practices.
``(2) Periodic financial disclosures.
``(3) Data on enrollment.
``(4) Data on disenrollment.
``(5) Data on the number of claims that are denied.
``(6) Data on rating practices.
``(7) Information on cost-sharing and payments with respect
to any out-of-network coverage (or with respect to any item and
service furnished under such a plan that does not use a network
of providers).
``(8) Information on participant and beneficiary rights
under this part.
``(9) Rate and payment information described in subsection
(d).
``(10) Other information as determined appropriate by the
Secretary.
Rate and payment information described in paragraph (9) shall be made
available to the public not later than January 10, 2025, and not later
than the tenth day of every month thereafter, in the manner described
in subsection (d)(2)(A), and, beginning on January 1, 2027, in real-
time through an application program interface (or successor technology)
described in subsection (d)(2)(B).
``(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain language. The
term `plain language' means language that the intended audience,
including individuals with limited English proficiency, can readily
understand and use because that language is clear, concise, well-
organized, accurately describes the information, and follows other best
practices of plain language writing. The Secretary, jointly with the
Secretary of Health and Human Services and the Secretary of Labor,
shall develop and issue standards for plain language writing for
purposes of this section and shall develop a standardized reporting
template and standardized definitions of terms to allow for comparison
across group health plans and health insurance coverage.
``(c) Cost Sharing Transparency.--
``(1) In general.--A group health plan shall, upon request
of a participant or beneficiary and in a timely manner, provide
to the participant or beneficiary a statement of the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the participant's or beneficiary's plan that
the participant or beneficiary would be responsible for paying
with respect to the furnishing of a specific item or service by
a provider. At a minimum, such information shall include the
information specified in paragraph (2) and shall be made
available at no cost to the participant or beneficiary through
a self-service tool that meets the requirements of paragraph
(3) or through a paper or phone disclosure, at the option of
the participant or beneficiary, that meets such requirements as
the Secretary may specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are available
under a group health plan furnished by a health care provider
to a participant or beneficiary of such plan, the following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate (as defined in subsection (f)) for such item or
service and for any other item or service that is
inherent in the furnishing of the item or service that
is the subject of such request.
``(B) If such provider is not a participating
provider, the allowed amount, percentage of billed
charges, or other rate that such plan will recognize as
payment for such item or service, along with a notice
that such individual may be liable for additional
charges billed by such provider.
``(C) The estimated amount of cost sharing
(including deductibles, copayments, and coinsurance)
that the participant or beneficiary will incur for such
item or service (which, in the case such item or
service is to be furnished by a provider described in
subparagraph (B), shall be calculated using the amount
or rate described in such subparagraph (or, in the case
such plan uses a percentage of billed charges to
determined the amount of payment for such provider,
using a reasonable estimate of such percentage of such
charges)).
``(D) The amount the participant or beneficiary has
already accumulated with respect to any deductible or
out of pocket maximum under the plan (broken down, in
the case separate deductibles or maximums apply to
separate participants and beneficiaries enrolled in the
plan, by such separate deductibles or maximums, in
addition to any cumulative deductible or maximum).
``(E) Any shared savings or other benefit available
to the participant or beneficiary with respect to such
item or service.
``(F) In the case such plan imposes any frequency
or volume limitations with respect to such item or
service (excluding medical necessity determinations),
the amount that such participant or beneficiary has
accrued towards such limitation with respect to such
item or service.
``(G) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan meets the
requirements of this paragraph if such tool--
``(A) is based on an Internet website, mobile
application, or other platform determined appropriate
by the Secretary;
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information
provided through such tool is accurate at the time such
request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such item or service
for purposes of facilitating price comparisons;
or
``(iii) a provider that is not described in
clause (ii); and
``(E) provides that such a request may be made with
respect to an item or service through use of the
billing code for such item or service or through use of
a descriptive term for such item or service.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing codes
to a single descriptive term if the Secretary determines that
the billing codes to be so linked correspond to items and
services.
``(4) Provider tool.--A group health plan shall permit
providers to learn the amount of cost-sharing (including
deductibles, copayments, and coinsurance) that would apply
under an individual's plan that the individual would be
responsible for paying with respect to the furnishing of a
specific item or service by another provider in a timely manner
upon the request of the provider and with the consent of such
individual in the same manner and to the same extent as if such
request has been made by such individual. As part of any tool
used to facilitate such requests from a provider, such plan may
include functionality that--
``(A) allows providers to submit the notifications
to such plan or coverage required under section 2799B-6
of the Public Health Services Act; and
``(B) provides for notifications required under
section 9816(f) to such an individual.
``(d) Rate and Payment Information.--
``(1) In general.--For purposes of subsection (a)(9), the
rate and payment information described in this subsection is,
with respect to a group health plan, the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan, the in-network rate (in a dollar amount) in
effect as of the first day of the plan year during
which such information is submitted with each provider
(identified by national provider identifier) that is a
participating provider with respect to such item or
service (or, in the case such rate is not available in
a dollar amount, such formulae, pricing methodologies,
or other information used to calculate such rate).
``(B) With respect to each dosage form and
indication of each drug (identified by national drug
code) for which benefits are available under such
plan--
``(i) the in-network rate (in a dollar
amount) in effect as of the first day of the
plan year during which such information is
submitted with each provider (identified by
national provider identifier) that is a
participating provider with respect to such
drug (or, in the case such rate is not
available in a dollar amount, such formulae,
pricing methodologies, or other information
used to calculate such rate); and
``(ii) the average amount paid by such plan
(net of rebates, discounts, and price
concessions) for such drug dispensed or
administered during the 90-day period beginning
180 days before such date of submission to each
provider that was a participating provider with
respect to such drug, broken down by each such
provider (identified by national provider
identifier), other than such an amount paid to
a provider that, during such period, submitted
fewer than 20 claims for such drug to such plan
or coverage.
``(C) With respect to each item or service for
which benefits are available under such plan, the
amount billed, and the amount allowed by the plan, for
each such item or service furnished during the 90-day
period specified in subparagraph (B) by a provider that
was not a participating provider with respect to such
item or service, broken down by each such provider
(identified by national provider identifier), other
than items and services with respect to which fewer
than 20 claims for such item or service were submitted
to such plan or coverage during such period.
Such rate and payment information shall be made available with
respect to each individual item or service, regardless of
whether such item or service is paid for as part of a bundled
payment, episode of care, value-based payment arrangement, or
otherwise.
``(2) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under subsection (a)(9)
shall be so made available in dollar amounts through 3
separate machine-readable files corresponding to the
information described in each of subparagraphs (A)
through (C) of paragraph (1) that meet such
requirements as specified by the Secretary not later
than 180 days after the date of the enactment of this
paragraph through rulemaking. Such requirements shall
ensure that such files are limited to an appropriate
size, do not include information that is duplicative of
information contained in other files made available
under such subsection, are made available in a widely-
available format that allows for information contained
in such files to be compared across group health plans,
and are accessible to individuals at no cost and
without the need to establish a user account or provide
other credentials.
``(B) Real-time provision of information.--
``(i) In general.--Subject to clause (ii),
beginning January 1, 2026, rate and payment
information required to be made available by a
group health plan under subsection (a)(9)
shall, in addition to being made available in
the manner described in subparagraph (A), be
made available through an application program
interface (or successor technology) that
provides access to such information in real
time and that meets such technical standards as
may be specified by the Secretary.
``(ii) Exemption for certain plans and
coverage.--Clause (i) shall not apply with
respect to information described in such clause
required to be made available by a group health
plan if such plan provides benefits for fewer
than 500 participants and beneficiaries.
``(3) User guide.--The Secretary, Secretary of Health and
Human Services, and Secretary of Labor shall jointly make
available to the public instructions written in plain language
explaining how individuals may search for information described
in paragraph (1) in files submitted in accordance with
paragraph (2).
``(4) Annual summary.--For each year (beginning with 2025),
each group health plan shall make public a machine-readable
file meeting such standards as established by the Secretary
under paragraph (2) containing a summary of all rate and
payment information made public by such plan with respect to
such plan or coverage during such year (such as averages of all
such information so made public).
``(e) Attestation.--Each group health plan shall annually submit to
the Secretary an attestation of such plan's compliance with the
provisions of this section along with a link to disclosures made in
accordance with subsection (a).
``(f) Definitions.--In this subsection:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 9816 and
includes a participating facility.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan and an item or service
furnished by a provider that is a participating provider with
respect to such plan and item or service, the contracted rate
(reflected as a dollar amount) in effect between such plan and
such provider for such item or service.''.
(B) Clerical amendment.--The item relating to
section 9819 in the table of sections for subchapter B
of chapter 100 of the Internal Revenue Code of 1986 is
amended to read as follows:
``Sec. 9819. Price transparency requirements.''.
(3) PHSA.--Section 2799A-4 of the Public Health Service Act
(42 U.S.C. 300gg-114) is amended to read as follows:
``SEC. 2799A-4. PRICE TRANSPARENCY REQUIREMENTS.
``(a) In General.--A group health plan, and a health insurance
issuer offering group or individual health insurance coverage, shall
make available to the public accurate and timely disclosures of the
following information:
``(1) Claims payment policies and practices.
``(2) Periodic financial disclosures.
``(3) Data on enrollment.
``(4) Data on disenrollment.
``(5) Data on the number of claims that are denied.
``(6) Data on rating practices.
``(7) Information on cost-sharing and payments with respect
to any out-of-network coverage (or with respect to any item and
service furnished under such a plan or such group or individual
health insurance coverage that does not use a network of
providers).
``(8) Information on enrollee rights under this part.
``(9) Rate and payment information described in subsection
(d).
``(10) Other information as determined appropriate by the
Secretary.
Rate and payment information described in paragraph (9) shall be made
available to the public not later than January 10, 2025, and not later
than the tenth day of every month thereafter, in the manner described
in subsection (d)(2)(A), and, beginning on January 1, 2027, in real-
time through an application program interface (or successor technology)
described in subsection (d)(2)(B).
``(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain language. The
term `plain language' means language that the intended audience,
including individuals with limited English proficiency, can readily
understand and use because that language is clear, concise, well-
organized, accurately describes the information, and follows other best
practices of plain language writing. The Secretary, jointly with the
Secretary of Labor and the Secretary of the Treasury, shall develop and
issue standards for plain language writing for purposes of this section
and shall develop a standardized reporting template and standardized
definitions of terms to allow for comparison across group health plans
and health insurance coverage.
``(c) Cost Sharing Transparency.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group or individual health insurance
coverage, shall, upon request of an enrollee and in a timely
manner, provide to the enrollee a statement of the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the enrollee's plan or coverage that the
enrollee would be responsible for paying with respect to the
furnishing of a specific item or service by a provider. At a
minimum, such information shall include the information
specified in paragraph (2) and shall be made available at no
cost to the enrollee through a self-service tool that meets the
requirements of paragraph (3) or through a paper or phone
disclosure, at the option of the enrollee, that meets such
requirements as the Secretary may specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are available
under a group health plan or group or individual health
insurance coverage (as applicable) furnished by a health care
provider to an enrollee of such plan or coverage, the
following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate (as defined in subsection (f)) for such item or
service and for any other item or service that is
inherent in the furnishing of the item or service that
is the subject of such request.
``(B) If such provider is not a participating
provider, the allowed amount, percentage of billed
charges, or other rate that such plan or coverage will
recognize as payment for such item or service, along
with a notice that such enrollee may be liable for
additional charges billed by such provider.
``(C) The estimated amount of cost sharing
(including deductibles, copayments, and coinsurance)
that the enrollee will incur for such item or service
(which, in the case such item or service is to be
furnished by a provider described in subparagraph (B),
shall be calculated using the amount or rate described
in such subparagraph (or, in the case such plan or
issuer uses a percentage of billed charges to
determined the amount of payment for such provider,
using a reasonable estimate of such percentage of such
charges)).
``(D) The amount the enrollee has already
accumulated with respect to any deductible or out of
pocket maximum under the plan or coverage (broken down,
in the case separate deductibles or maximums apply to
separate enrollees in the plan or coverage, by such
separate deductibles or maximums, in addition to any
cumulative deductible or maximum).
``(E) Any shared savings or other benefit available
to the enrollee with respect to such item or service.
``(F) In the case such plan or coverage imposes any
frequency or volume limitations with respect to such
item or service (excluding medical necessity
determinations), the amount that such enrollee has
accrued towards such limitation with respect to such
item or service.
``(G) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan or group or individual health insurance
coverage.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan or health
insurance issuer offering group or individual health insurance
coverage meets the requirements of this paragraph if such
tool--
``(A) is based on an Internet website, mobile
application, or other platform determined appropriate
by the Secretary;
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information
provided through such tool is accurate at the time such
request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such plan and such
item or service for purposes of facilitating
price comparisons; or
``(iii) a provider that is not described in
clause (ii); and
``(E) provides that such a request may be made with
respect to an item or service through use of the
billing code for such item or service or through use of
a descriptive term for such item or service.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing codes
to a single descriptive term if the Secretary determines that
the billing codes to be so linked correspond to items and
services.
``(4) Provider tool.--A group health plan, and a health
insurance issuer offering group or individual health insurance
coverage, shall permit providers to learn the amount of cost-
sharing (including deductibles, copayments, and coinsurance)
that would apply under an individual's plan or coverage that
the individual would be responsible for paying with respect to
the furnishing of a specific item or service by another
provider in a timely manner upon the request of the provider
and with the consent of such individual in the same manner and
to the same extent as if such request has been made by such
individual. As part of any tool used to facilitate such
requests from a provider, such plan or issuer offering health
insurance coverage may include functionality that--
``(A) allows providers to submit the notifications
to such plan or coverage required under section 2799B-
6; and
``(B) provides for notifications required under
section 2799A-1(f) to such an individual.
``(d) Rate and Payment Information.--
``(1) In general.--For purposes of subsection (a)(9), the
rate and payment information described in this subsection is,
with respect to a group health plan or group or individual
health insurance coverage (as applicable), the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan or coverage, the in-network rate (in a dollar
amount) in effect as of the first day of the plan year
during which such information is submitted with each
provider (identified by national provider identifier)
that is a participating provider with respect to such
item or service (or, in the case such rate is not
available in a dollar amount, such formulae, pricing
methodologies, or other information used to calculate
such rate).
``(B) With respect to each dosage form and
indication of each drug (identified by national drug
code) for which benefits are available under such plan
or coverage--
``(i) the in-network rate (in a dollar
amount) in effect as of the first day of the
plan year during which such information is
submitted with each provider (identified by
national provider identifier) that is a
participating provider with respect to such
drug (or, in the case such rate is not
available in a dollar amount, such formulae,
pricing methodologies, or other information
used to calculate such rate); and
``(ii) the average amount paid by such plan
(net of rebates, discounts, and price
concessions) for such drug dispensed or
administered during the 90-day period beginning
180 days before such date of submission to each
provider that was a participating provider with
respect to such drug, broken down by each such
provider (identified by national provider
identifier), other than such an amount paid to
a provider that, during such period, submitted
fewer than 20 claims for such drug to such plan
or coverage.
``(C) With respect to each item or service for
which benefits are available under such plan or
coverage, the amount billed, and the amount allowed by
the plan or coverage, for each such item or service
furnished during the 90-day period specified in
subparagraph (B) by a provider that was not a
participating provider with respect to such item or
service, broken down by each such provider (identified
by national provider identifier), other than items and
services with respect to which fewer than 20 claims for
such item or service were submitted to such plan or
coverage during such period.
Such rate and payment information shall be made available with
respect to each individual item or service, regardless of
whether such item or service is paid for as part of a bundled
payment, episode of care, value-based payment arrangement, or
otherwise.
``(2) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under subsection (a)(9)
shall be so made available in dollar amounts through 3
separate machine-readable files corresponding to the
information described in each of subparagraphs (A)
through (C) of paragraph (1) that meet such
requirements as specified by the Secretary not later
than 180 days after the date of the enactment of this
paragraph through rulemaking. Such requirements shall
ensure that such files are limited to an appropriate
size, do not include information that is duplicative of
information contained in other files made available
under such subsection, are made available in a widely-
available format that allows for information contained
in such files to be compared across group health plans
and group or individual health insurance coverage, and
are accessible to individuals at no cost and without
the need to establish a user account or provide other
credentials.
``(B) Real-time provision of information.--
``(i) In general.--Subject to clause (ii),
beginning January 1, 2026, rate and payment
information required to be made available by a
group health plan or health insurance issuer
under subsection (a)(9) shall, in addition to
being made available in the manner described in
subparagraph (A), be made available through an
application program interface (or successor
technology) that provides access to such
information in real time and that meets such
technical standards as may be specified by the
Secretary.
``(ii) Exemption for certain plans and
coverage.--Clause (i) shall not apply with
respect to information described in such clause
required to be made available by a group health
plan or health insurance issuer offering health
insurance coverage if such plan or coverage, as
applicable, provides benefits for fewer than
500 enrollees.
``(3) User guide.--The Secretary, Secretary of Labor, and
Secretary of the Treasury shall jointly make available to the
public instructions written in plain language explaining how
individuals may search for information described in paragraph
(1) in files submitted in accordance with paragraph (2).
``(4) Annual summary.--For each year (beginning with 2025),
each group health plan and health insurance issuer offering
group or individual health insurance coverage shall make public
a machine-readable file meeting such standards as established
by the Secretary under paragraph (2) containing a summary of
all rate and payment information made public by such plan or
issuer with respect to such plan or coverage during such year
(such as averages of all such information so made public).
``(e) Attestation.--Each group health plan and health insurance
issuer offering group or individual health insurance coverage shall
annually submit to the Secretary an attestation of such plan's or such
coverage's compliance with the provisions of this section along with a
link to disclosures made in accordance with subsection (a).
``(f) Definitions.--In this subsection:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 2799A-1
and includes a participating facility.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group or individual
health insurance coverage and an item or service furnished by a
provider that is a participating provider with respect to such
plan or coverage and item or service, the contracted rate
(reflected as a dollar amount) in effect between such plan or
coverage and such provider for such item or service.''.
(b) Reports to Congress.--
(1) Quality report.--Not later than 1 year after the date
of enactment of this subsection, the Secretary of Labor shall
submit to Congress a report on the feasibility of including
data relating to the quality of health care items and services
with the price transparency information required to be made
available under the amendments made by subsection (a). Such
report shall include recommendations for legislative and
regulatory actions to identify appropriate metrics for
assessing and comparing quality of care.
(2) Transparency data assessment.--Not later than January
1, 2026, and biannually thereafter through 2032, the Secretary
shall submit to Congress, and make publicly available on a
website of the Department of Labor, a report with respect to
the information described in section 719 of the Employee
Retirement Income Security Act (29 U.S.C. 1185h) (as amended by
the ``Transparency in Coverage Act of 2023''), assessing the
differences in commercial negotiated prices--
(A) between rural and urban markets;
(B) in the individual, small-employer, and large-
employer markets;
(C) in consolidated and non-consolidated provider
markets;
(D) between non-profit and for-profit hospitals;
and
(E) between non-profit and for-profit insurers.
(c) Effective Date.--
(1) In general.--The amendments made by subsection (a)
shall apply to plan years beginning on or after January 1,
2025.
(2) Continued applicability of rules for previous years.--
Nothing in the amendments made by subsection (a) may be
construed as affecting the applicability of the rule entitled
``Transparency in Coverage'' published by the Department of the
Treasury, the Department of Labor, and the Department of Health
and Human Services on November 12, 2020 (85 Fed. Reg. 72158)
for plan years beginning before January 1, 2025.
SEC. 3. PHARMACY BENEFIT MANAGER TRANSPARENCY.
(a) ERISA.--
(1) In general.--Subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1021 et seq.)
is amended--
(A) in subpart B of part 7 (29 U.S.C. 1185 et
seq.), by adding at the end the following:
``SEC. 726. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after January 1,
2025, a group health plan (or health insurance issuer offering group
health insurance coverage in connection with such a plan) or an entity
or subsidiary providing pharmacy benefits management services on behalf
of such a plan or issuer may not enter into a contract with a drug
manufacturer, distributor, wholesaler, switch, patient or copay
assistance program administrator, pharmacy, subcontractor, rebate
aggregator, or any associated third party that limits or delays the
disclosure of information to plan administrators in such a manner that
prevents the plan or issuer, or an entity or subsidiary providing
pharmacy benefits management services on behalf of a plan or issuer,
from making or substantiating the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly (and upon
request by the plan administrator), a group health plan or
health insurance issuer offering group health insurance
coverage, or an entity providing pharmacy benefits management
services on behalf of a group health plan or an issuer
providing group health insurance coverage, shall submit to the
plan administrator (as defined in section 3(16)(A)) of such
plan or coverage a report in accordance with this subsection,
and make such report available to the plan administrator in a
machine-readable format (or as may be determined by the
Secretary, other formats). Each such report shall include, with
respect to the applicable group health plan or health insurance
coverage--
``(A) information collected from a patient or copay
assistance program administrator by such entity on the
total amount of copayment assistance dollars paid, or
copayment cards applied, or other discounts that were
funded by the drug manufacturer with respect to the
participants and beneficiaries in such plan or
coverage;
``(B) total gross spending on prescription drugs by
the plan or coverage during the reporting period;
``(C) total amount received, or expected to be
received, by the plan or coverage from any entities, in
rebates, fees, alternative discounts, and all other
remuneration received from the entity or any third
party (including group purchasing organizations) other
than the plan administrator, related to utilization of
drug or drug spending under such plan or coverage
during the reporting period;
``(D) the total net spending on prescription drugs
by the plan or coverage during such reporting period;
``(E) amounts paid, directly or indirectly, in
rebates, fees, or any other type of compensation (as
defined in section 408(b)(2)(B)(ii)(dd)(AA)) to
brokerage houses, brokers, consultants, advisors, or
any other individual or firm for the referral of the
group health plan's or health insurance issuer's
business to the pharmacy benefits manager, identified
by the recipient of such amounts;
``(F)(i) an explanation of any benefit design
parameters that encourage or require participants and
beneficiaries in the plan or coverage to fill
prescriptions at mail order, specialty, or retail
pharmacies that are affiliated with or under common
ownership with the entity providing pharmacy benefit
management services under such plan or coverage,
including mandatory mail and specialty home delivery
programs, retail and mail auto-refill programs, and
cost-sharing assistance incentives funded by an entity
providing pharmacy benefit management services;
``(ii) the percentage of total
prescriptions charged to the plan, issuer, or
participants and beneficiaries in such plan or
coverage, that were dispensed by mail order,
specialty, or retail pharmacies that are
affiliated with or under common ownership with
the entity providing pharmacy benefit
management services; and
``(iii) a list of all drugs dispensed by
such affiliated pharmacy or pharmacy under
common ownership and charged to the plan,
issuer, or participants and beneficiaries of
the plan, during the applicable period, and,
with respect to each drug--
``(I)(aa) the amount charged, per
dosage unit, per 30-day supply, and per
90-day supply, with respect to
participants and beneficiaries in the
plan or coverage, to the plan or
issuer; and
``(bb) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
to participants and
beneficiaries;
``(II) the median amount charged to
the plan or issuer, per dosage unit,
per 30-day supply, and per 90-day
supply, including amounts paid by the
participants and beneficiaries, when
the same drug is dispensed by other
pharmacies that are not affiliated with
or under common ownership with the
entity and that are included in the
pharmacy network of such plan or
coverage;
``(III) the interquartile range of
the costs, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, when
the same drug is dispensed by other
pharmacies that are not affiliated with
or under common ownership with the
entity and that are included in the
pharmacy network of that plan or
coverage;
``(IV) the lowest cost, per dosage
unit, per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan and
participants and beneficiaries, that is
available from any pharmacy included in
the network of the plan or coverage;
``(V) the net acquisition cost per
dosage unit, per 30-day supply, and per
90-day supply, if the drug is subject
to a maximum price discount; and
``(VI) other information with
respect to the cost of the drug, as
determined by the Secretary, such as
average sales price, wholesale
acquisition cost, and national average
drug acquisition cost per dosage unit
or per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan or issuer
and participants and beneficiaries
among all pharmacies included in the
network of such plan or coverage; and
``(G) in the case of a large employer--
``(i) a list of each drug covered by such
plan, issuer, or entity providing pharmacy
benefits management services for which a claim
was filed during the reporting period,
including, with respect to each such drug
during the reporting period--
``(I) the brand name, generic or
non-proprietary name, and the National
Drug Code;
``(II)(aa) the number of
participants and beneficiaries for whom
a claim for such drug was filed during
the reporting period, the total number
of prescription claims for such drug
(including original prescriptions and
refills), and the total number of
dosage units and total days supply of
such drug for which a claim was filed
during the reporting period; and
``(bb) with respect to each
claim or dosage unit described
in item (aa), the type of
dispensing channel used, such
as retail, mail order, or
specialty pharmacy;
``(III) the wholesale acquisition
cost, listed as cost per days supply
and cost per dosage unit on date of
dispensing;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug after
application of any benefits under such
plan or coverage, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles (but not including any
amounts spent by participants and
beneficiaries on drugs not covered
under such plan or coverage, or for
which no claim was submitted to such
plan or coverage);
``(V) for any drug for which gross
spending of the plan or coverage
exceeded $10,000 during the reporting
period--
``(aa) a list of all other
drugs in the same therapeutic
category or class, including
brand name drugs, biological
products, generic drugs, or
biosimilar biological products
that are in the same
therapeutic category or class
as such drug; and
``(bb) the rationale for
preferred formulary placement
of such drug in that
therapeutic category or class,
if applicable; and
``(ii) a list of each therapeutic category
or class of drugs for which a claim was filed
under the health plan or health insurance
coverage during the reporting period, and, with
respect to each such therapeutic category or
class of drugs during the reporting period--
``(I) total gross spending by the
plan;
``(II) the number of participants
and beneficiaries who filled a
prescription for a drug in that
category or class;
``(III) if applicable to that
category or class, a description of the
formulary tiers and utilization
mechanisms (such as prior authorization
or step therapy) employed for drugs in
that category or class;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles; and
``(V) for each drug--
``(aa) the amount received,
or expected to be received,
from any entity in rebates,
fees, alternative discounts, or
other remuneration--
``(AA) for claims
incurred during the
reporting period; or
``(BB) that is
related to utilization
of drugs or drug
spending;
``(bb) the total net
spending, after deducting
rebates, price concessions,
alternative discounts or other
remuneration from drug
manufacturers, by the health
plan or health insurance
coverage on that category or
class of drugs; and
``(cc) the average net
spending per 30-day supply and
per 90-day supply, incurred by
the health plan or health
insurance coverage and its
participants and beneficiaries,
among all drugs within the
therapeutic class for which a
claim was filed during the
reporting period.
``(2) Privacy requirements.--Health insurance issuers
offering group health insurance coverage and entities providing
pharmacy benefits management services on behalf of a group
health plan shall provide information under paragraph (1) in a
manner consistent with the privacy, security, and breach
notification regulations promulgated under section 264(c) of
the Health Insurance Portability and Accountability Act of
1996, and shall restrict the use and disclosure of such
information according to such privacy regulations.
``(3) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group
health plan receiving a report under paragraph (1) may
disclose such information only to business associates
of such plan as defined in section 160.103 of title 45,
Code of Federal Regulations (or successor regulations).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section prevents a health
insurance issuer offering group health insurance
coverage or an entity providing pharmacy benefits
management services on behalf of a group health plan
from placing reasonable restrictions on the public
disclosure of the information contained in a report
described in paragraph (1), except that such entity may
not restrict disclosure of such report to the
Department of Health and Human Services, the Department
of Labor, the Department of the Treasury, the
Comptroller General of the United States, or applicable
State agencies.
``(C) Limited form of report.--The Secretary shall
define through rulemaking a limited form of the report
under paragraph (1) required of plan administrators who
are drug manufacturers, drug wholesalers, or other
direct participants in the drug supply chain, in order
to prevent anti-competitive behavior.
``(4) Report to gao.--A health insurance issuer offering
group health insurance coverage or an entity providing pharmacy
benefits management services on behalf of a group health plan
shall submit to the Comptroller General of the United States
each of the first 4 reports submitted to a plan administrator
under paragraph (1) with respect to such coverage or plan, and
other such reports as requested, in accordance with the privacy
requirements under paragraph (2), the disclosure and
redisclosure standards under paragraph (3), the standards
specified pursuant to paragraph (5).
``(5) Standard format.--Not later than 6 months after the
date of enactment of this section, the Secretary shall specify
through rulemaking standards for health insurance issuers and
entities required to submit reports under paragraph (4) to
submit such reports in a standard format.
``(c) Rule of Construction.--Nothing in this section shall be
construed to permit a health insurance issuer, group health plan, or
other entity to restrict disclosure to, or otherwise limit the access
of, the Department of Labor to a report described in subsection (b)(1)
or information related to compliance with subsection (a) by such
issuer, plan, or entity.
``(d) Definitions.--In this section:
``(1) Large employer.--The term `large employer' means, in
connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at
least 50 employees on business days during the preceding
calendar year and who employs at least 1 employee on the first
day of the plan year.
``(2) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act.''; and
(B) in section 502 (29 U.S.C. 1132)--
(i) in subsection (a)--
(I) in paragraph (6), by striking
``or (9)'' and inserting ``(9), or
(13)'';
(II) in paragraph (10), by striking
at the end ``or'';
(III) in paragraph (11), at the end
by striking the period and inserting
``; or''; and
(IV) by adding at the end the
following new paragraph:
``(12) by the Secretary, to enforce section 726.'';
(ii) in subsection (b)(3), by inserting
``and subsections (a)(12) and (c)(13)'' before
``, the Secretary is not''; and
(iii) in subsection (c), by adding at the
end the following new paragraph:
``(13) Secretarial enforcement authority relating to
oversight of pharmacy benefits manager services.--
``(A) Failure to provide timely information.--The
Secretary may impose a penalty against any health
insurance issuer or entity providing pharmacy benefits
management services that violates section 726(a) or
fails to provide information required under section
726(b) in the amount of $10,000 for each day during
which such violation continues or such information is
not disclosed or reported.
``(B) False information.--The Secretary may impose
a penalty against a health insurance issuer or entity
providing pharmacy benefits management services that
knowingly provides false information under section 726
in an amount not to exceed $100,000 for each item of
false information. Such penalty shall be in addition to
other penalties as may be prescribed by law.
``(C) Waivers.--The Secretary may waive penalties
under subparagraph (A), or extend the period of time
for compliance with a requirement of section 726, for
an entity in violation of such section that has made a
good-faith effort to comply with such section.''.
(2) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1001 et seq.) is amended by inserting after the item
relating to section 725 the following new item:
``Sec. 726. Oversight of pharmacy benefits manager services.''.
(b) PHSA.--Part D of title XXVII of the Public Health Service Act
(42 U.S.C. 300gg-111 et seq.) is amended by adding at the end the
following new section:
``SEC. 2799A-11. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after January 1,
2025, a group health plan (or health insurance issuer offering group
health insurance coverage in connection with such a plan) or an entity
or subsidiary providing pharmacy benefits management services on behalf
of such a plan or issuer may not enter into a contract with a drug
manufacturer, distributor, wholesaler, switch, patient or copay
assistance program administrator, pharmacy, subcontractor, rebate
aggregator, or any associated third party that limits or delays the
disclosure of information to plan administrators in such a manner that
prevents the plan or issuer, or an entity or subsidiary providing
pharmacy benefits management services on behalf of a plan or issuer,
from making or substantiating the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly (and upon
request by the plan administrator), a group health plan or
health insurance issuer offering group health insurance
coverage, or an entity providing pharmacy benefits management
services on behalf of a group health plan or an issuer
providing group health insurance coverage, shall submit to the
plan administrator (as defined in section 3(16)(A) of the
Employee Retirement Income Security Act of 1974) of such plan
or coverage a report in accordance with this subsection, and
make such report available to the plan administrator in a
machine-readable format (or as may be determined by the
Secretary, other formats). Each such report shall include, with
respect to the applicable group health plan or health insurance
coverage--
``(A) information collected from a patient or copay
assistance program administrator by such entity on the
total amount of copayment assistance dollars paid, or
copayment cards applied, or other discounts that were
funded by the drug manufacturer with respect to the
participants and beneficiaries in such plan or
coverage;
``(B) total gross spending on prescription drugs by
the plan or coverage during the reporting period;
``(C) total amount received, or expected to be
received, by the plan or coverage from any entities, in
rebates, fees, alternative discounts, and all other
remuneration received from the entity or any third
party (including group purchasing organizations) other
than the plan administrator, related to utilization of
drug or drug spending under such plan or coverage
during the reporting period;
``(D) the total net spending on prescription drugs
by the plan or coverage during such reporting period;
``(E) amounts paid, directly or indirectly, in
rebates, fees, or any other type of compensation (as
defined in section 408(b)(2)(B)(ii)(dd)(AA) of the
Employee Retirement Income Security Act of 1974) to
brokerage houses, brokers, consultants, advisors, or
any other individual or firm for the referral of the
group health plan's or health insurance issuer's
business to the pharmacy benefits manager, identified
by the recipient of such amounts;
``(F)(i) an explanation of any benefit design
parameters that encourage or require participants and
beneficiaries in the plan or coverage to fill
prescriptions at mail order, specialty, or retail
pharmacies that are affiliated with or under common
ownership with the entity providing pharmacy benefit
management services under such plan or coverage,
including mandatory mail and specialty home delivery
programs, retail and mail auto-refill programs, and
cost-sharing assistance incentives funded by an entity
providing pharmacy benefit management services;
``(ii) the percentage of total
prescriptions charged to the plan, issuer, or
participants and beneficiaries in such plan or
coverage, that were dispensed by mail order,
specialty, or retail pharmacies that are
affiliated with or under common ownership with
the entity providing pharmacy benefit
management services; and
``(iii) a list of all drugs dispensed by
such affiliated pharmacy or pharmacy under
common ownership and charged to the plan,
issuer, or participants and beneficiaries of
the plan, during the applicable period, and,
with respect to each drug--
``(I)(aa) the amount charged, per
dosage unit, per 30-day supply, and per
90-day supply, with respect to
participants and beneficiaries in the
plan or coverage, to the plan or
issuer; and
``(bb) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
to participants and
beneficiaries;
``(II) the median amount charged to
the plan or issuer, per dosage unit,
per 30-day supply, and per 90-day
supply, including amounts paid by the
participants and beneficiaries, when
the same drug is dispensed by other
pharmacies that are not affiliated with
or under common ownership with the
entity and that are included in the
pharmacy network of such plan or
coverage;
``(III) the interquartile range of
the costs, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, when
the same drug is dispensed by other
pharmacies that are not affiliated with
or under common ownership with the
entity and that are included in the
pharmacy network of that plan or
coverage;
``(IV) the lowest cost, per dosage
unit, per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan and
participants and beneficiaries, that is
available from any pharmacy included in
the network of the plan or coverage;
``(V) the net acquisition cost per
dosage unit, per 30-day supply, and per
90-day supply, if the drug is subject
to a maximum price discount; and
``(VI) other information with
respect to the cost of the drug, as
determined by the Secretary, such as
average sales price, wholesale
acquisition cost, and national average
drug acquisition cost per dosage unit
or per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan or issuer
and participants and beneficiaries
among all pharmacies included in the
network of such plan or coverage; and
``(G) in the case of a large employer--
``(i) a list of each drug covered by such
plan, issuer, or entity providing pharmacy
benefits management services for which a claim
was filed during the reporting period,
including, with respect to each such drug
during the reporting period--
``(I) the brand name, generic or
non-proprietary name, and the National
Drug Code;
``(II)(aa) the number of
participants and beneficiaries for whom
a claim for such drug was filed during
the reporting period, the total number
of prescription claims for such drug
(including original prescriptions and
refills), and the total number of
dosage units and total days supply of
such drug for which a claim was filed
during the reporting period; and
``(bb) with respect to each
claim or dosage unit described
in item (aa), the type of
dispensing channel used, such
as retail, mail order, or
specialty pharmacy;
``(III) the wholesale acquisition
cost, listed as cost per days supply
and cost per dosage unit on date of
dispensing;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug after
application of any benefits under such
plan or coverage, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles (but not including any
amounts spent by participants and
beneficiaries on drugs not covered
under such plan or coverage, or for
which no claim was submitted to such
plan or coverage);
``(V) for any drug for which gross
spending of the plan or coverage
exceeded $10,000 during the reporting
period--
``(aa) a list of all other
drugs in the same therapeutic
category or class, including
brand name drugs, biological
products, generic drugs, or
biosimilar biological products
that are in the same
therapeutic category or class
as such drug; and
``(bb) the rationale for
preferred formulary placement
of such drug in that
therapeutic category or class,
if applicable; and
``(ii) a list of each therapeutic category
or class of drugs for which a claim was filed
under the health plan or health insurance
coverage during the reporting period, and, with
respect to each such therapeutic category or
class of drugs during the reporting period--
``(I) total gross spending by the
plan;
``(II) the number of participants
and beneficiaries who filled a
prescription for a drug in that
category or class;
``(III) if applicable to that
category or class, a description of the
formulary tiers and utilization
mechanisms (such as prior authorization
or step therapy) employed for drugs in
that category or class;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles; and
``(V) for each drug--
``(aa) the amount received,
or expected to be received,
from any entity in rebates,
fees, alternative discounts, or
other remuneration--
``(AA) for claims
incurred during the
reporting period; or
``(BB) that is
related to utilization
of drugs or drug
spending;
``(bb) the total net
spending, after deducting
rebates, price concessions,
alternative discounts or other
remuneration from drug
manufacturers, by the health
plan or health insurance
coverage on that category or
class of drugs; and
``(cc) the average net
spending per 30-day supply and
per 90-day supply, incurred by
the health plan or health
insurance coverage and its
participants and beneficiaries,
among all drugs within the
therapeutic class for which a
claim was filed during the
reporting period.
``(2) Privacy requirements.--Health insurance issuers
offering group health insurance coverage and entities providing
pharmacy benefits management services on behalf of a group
health plan shall provide information under paragraph (1) in a
manner consistent with the privacy, security, and breach
notification regulations promulgated under section 264(c) of
the Health Insurance Portability and Accountability Act of
1996, and shall restrict the use and disclosure of such
information according to such privacy regulations.
``(3) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group
health plan receiving a report under paragraph (1) may
disclose such information only to business associates
of such plan as defined in section 160.103 of title 45,
Code of Federal Regulations (or successor regulations).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section prevents a health
insurance issuer offering group health insurance
coverage or an entity providing pharmacy benefits
management services on behalf of a group health plan
from placing reasonable restrictions on the public
disclosure of the information contained in a report
described in paragraph (1), except that such issuer or
entity may not restrict disclosure of such report to
the Department of Health and Human Services, the
Department of Labor, the Department of the Treasury,
the Comptroller General of the United States, or
applicable State agencies.
``(C) Limited form of report.--The Secretary shall
define through rulemaking a limited form of the report
under paragraph (1) required of plan administrators who
are drug manufacturers, drug wholesalers, or other
direct participants in the drug supply chain, in order
to prevent anti-competitive behavior.
``(4) Report to gao.--A health insurance issuer offering
group health insurance coverage or an entity providing pharmacy
benefits management services on behalf of a group health plan
shall submit to the Comptroller General of the United States
each of the first 4 reports submitted to a plan administrator
under paragraph (1) with respect to such coverage or plan, and
other such reports as requested, in accordance with the privacy
requirements under paragraph (2), the disclosure and
redisclosure standards under paragraph (3), the standards
specified pursuant to paragraph (5).
``(5) Standard format.--Not later than 6 months after the
date of enactment of this section, the Secretary shall specify
through rulemaking standards for health insurance issuers and
entities required to submit reports under paragraph (4) to
submit such reports in a standard format.
``(c) Enforcement.--
``(1) Failure to provide timely information.--An entity
providing pharmacy benefits management services that violates
subsection (a) or fails to provide information required under
subsection (b) shall be subject to a civil monetary penalty in
the amount of $10,000 for each day during which such violation
continues or such information is not disclosed or reported.
``(2) False information.--An entity providing pharmacy
benefits management services that knowingly provides false
information under this section shall be subject to a civil
money penalty in an amount not to exceed $100,000 for each item
of false information. Such civil money penalty shall be in
addition to other penalties as may be prescribed by law.
``(3) Procedure.--The provisions of section 1128A of the
Social Security Act, other than subsection (a) and (b) and the
first sentence of subsection (c)(1) of such section shall apply
to civil monetary penalties under this subsection in the same
manner as such provisions apply to a penalty or proceeding
under section 1128A of the Social Security Act.
``(4) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance with
a requirement of this section, for an entity in violation of
this section that has made a good-faith effort to comply with
this section.
``(d) Rule of Construction.--Nothing in this section shall be
construed to permit a health insurance issuer, group health plan, or
other entity to restrict disclosure to, or otherwise limit the access
of, the Department of Health and Human Services to a report described
in subsection (b)(1) or information related to compliance with
subsection (a) by such issuer, plan, or entity.
``(e) Definitions.--In this section:
``(1) Large employer.--The term `large employer' means, in
connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at
least 50 employees on business days during the preceding
calendar year and who employs at least 1 employee on the first
day of the plan year.
``(2) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act.''.
(c) IRC.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new section:
``SEC. 9826. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after January 1,
2025, a group health plan or an entity or subsidiary providing pharmacy
benefits management services on behalf of such a plan may not enter
into a contract with a drug manufacturer, distributor, wholesaler,
switch, patient or copay assistance program administrator, pharmacy,
subcontractor, rebate aggregator, or any associated third party that
limits or delays the disclosure of information to plan administrators
in such a manner that prevents the plan, or an entity or subsidiary
providing pharmacy benefits management services on behalf of a plan,
from making or substantiating the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly (and upon
request by the plan administrator), a group health plan, or an
entity providing pharmacy benefits management services on
behalf of a group health plan, shall submit to the plan
administrator (as defined in section 3(16)(A) of the Employee
Retirement Income Security Act of 1974) of such plan a report
in accordance with this subsection, and make such report
available to the plan administrator in a machine-readable
format (or as may be determined by the Secretary, other
formats). Each such report shall include, with respect to the
applicable group health plan--
``(A) information collected from a patient or copay
assistance program administrator by such entity on the
total amount of copayment assistance dollars paid, or
copayment cards applied, or other discounts that were
funded by the drug manufacturer with respect to the
participants and beneficiaries in such plan;
``(B) total gross spending on prescription drugs by
the plan during the reporting period;
``(C) total amount received, or expected to be
received, by the plan from any entities, in rebates,
fees, alternative discounts, and all other remuneration
received from the entity or any third party (including
group purchasing organizations) other than the plan
administrator, related to utilization of drug or drug
spending under such plan during the reporting period;
``(D) the total net spending on prescription drugs
by the plan during such reporting period;
``(E) amounts paid, directly or indirectly, in
rebates, fees, or any other type of compensation (as
defined in section 408(b)(2)(B)(ii)(dd)(AA) of the
Employee Retirement Income Security Act of 1974) to
brokerage houses, brokers, consultants, advisors, or
any other individual or firm for the referral of the
group health plan's business to the pharmacy benefits
manager, identified by the recipient of such amounts;
``(F)(i) an explanation of any benefit design
parameters that encourage or require participants and
beneficiaries in the plan to fill prescriptions at mail
order, specialty, or retail pharmacies that are
affiliated with or under common ownership with the
entity providing pharmacy benefit management services
under such plan, including mandatory mail and specialty
home delivery programs, retail and mail auto-refill
programs, and cost-sharing assistance incentives funded
by an entity providing pharmacy benefit management
services;
``(ii) the percentage of total
prescriptions charged to the plan, or
participants and beneficiaries in such plan,
that were dispensed by mail order, specialty,
or retail pharmacies that are affiliated with
or under common ownership with the entity
providing pharmacy benefit management services;
and
``(iii) a list of all drugs dispensed by
such affiliated pharmacy or pharmacy under
common ownership and charged to the plan, or
participants and beneficiaries of the plan,
during the applicable period, and, with respect
to each drug--
``(I)(aa) the amount charged, per
dosage unit, per 30-day supply, and per
90-day supply, with respect to
participants and beneficiaries in the
plan, to the plan; and
``(bb) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
to participants and
beneficiaries;
``(II) the median amount charged to
the plan, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, when
the same drug is dispensed by other
pharmacies that are not affiliated with
or under common ownership with the
entity and that are included in the
pharmacy network of such plan;
``(III) the interquartile range of
the costs, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, when
the same drug is dispensed by other
pharmacies that are not affiliated with
or under common ownership with the
entity and that are included in the
pharmacy network of that plan;
``(IV) the lowest cost, per dosage
unit, per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan and
participants and beneficiaries, that is
available from any pharmacy included in
the network of the plan;
``(V) the net acquisition cost per
dosage unit, per 30-day supply, and per
90-day supply, if the drug is subject
to a maximum price discount; and
``(VI) other information with
respect to the cost of the drug, as
determined by the Secretary, such as
average sales price, wholesale
acquisition cost, and national average
drug acquisition cost per dosage unit
or per 30-day supply, and per-90 day
supply, for such drug, including
amounts charged to the plan and
participants and beneficiaries among
all pharmacies included in the network
of such plan; and
``(G) in the case of a large employer--
``(i) a list of each drug covered by such
plan or entity providing pharmacy benefits
management services for which a claim was filed
during the reporting period, including, with
respect to each such drug during the reporting
period--
``(I) the brand name, generic or
non-proprietary name, and the National
Drug Code;
``(II)(aa) the number of
participants and beneficiaries for whom
a claim for such drug was filed during
the reporting period, the total number
of prescription claims for such drug
(including original prescriptions and
refills), and the total number of
dosage units and total days supply of
such drug for which a claim was filed
during the reporting period; and
``(bb) with respect to each
claim or dosage unit described
in item (aa), the type of
dispensing channel used, such
as retail, mail order, or
specialty pharmacy;
``(III) the wholesale acquisition
cost, listed as cost per days supply
and cost per dosage unit on date of
dispensing;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug after
application of any benefits under such
plan, including participant and
beneficiary spending through
copayments, coinsurance, and
deductibles (but not including any
amounts spent by participants and
beneficiaries on drugs not covered
under such plan, or for which no claim
was submitted to such plan);
``(V) for any drug for which gross
spending of the plan exceeded $10,000
during the reporting period--
``(aa) a list of all other
drugs in the same therapeutic
category or class, including
brand name drugs, biological
products, generic drugs, or
biosimilar biological products
that are in the same
therapeutic category or class
as such drug; and
``(bb) the rationale for
preferred formulary placement
of such drug in that
therapeutic category or class,
if applicable; and
``(ii) a list of each therapeutic category
or class of drugs for which a claim was filed
under the plan during the reporting period,
and, with respect to each such therapeutic
category or class of drugs during the reporting
period--
``(I) total gross spending by the
plan;
``(II) the number of participants
and beneficiaries who filled a
prescription for a drug in that
category or class;
``(III) if applicable to that
category or class, a description of the
formulary tiers and utilization
mechanisms (such as prior authorization
or step therapy) employed for drugs in
that category or class;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles; and
``(V) for each drug--
``(aa) the amount received,
or expected to be received,
from any entity in rebates,
fees, alternative discounts, or
other remuneration--
``(AA) for claims
incurred during the
reporting period; or
``(BB) that is
related to utilization
of drugs or drug
spending;
``(bb) the total net
spending, after deducting
rebates, price concessions,
alternative discounts or other
remuneration from drug
manufacturers, by the plan on
that category or class of
drugs; and
``(cc) the average net
spending per 30-day supply and
per 90-day supply, incurred by
the plan and its participants
and beneficiaries, among all
drugs within the therapeutic
class for which a claim was
filed during the reporting
period.
``(2) Privacy requirements.--Entities providing pharmacy
benefits management services on behalf of a group health plan
shall provide information under paragraph (1) in a manner
consistent with the privacy, security, and breach notification
regulations promulgated under section 264(c) of the Health
Insurance Portability and Accountability Act of 1996, and shall
restrict the use and disclosure of such information according
to such privacy regulations.
``(3) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group
health plan receiving a report under paragraph (1) may
disclose such information only to business associates
of such plan as defined in section 160.103 of title 45,
Code of Federal Regulations (or successor regulations).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section prevents an
entity providing pharmacy benefits management services
on behalf of a group health plan from placing
reasonable restrictions on the public disclosure of the
information contained in a report described in
paragraph (1), except that such entity may not restrict
disclosure of such report to the Department of Health
and Human Services, the Department of Labor, the
Department of the Treasury, the Comptroller General of
the United States, or applicable State agencies.
``(C) Limited form of report.--The Secretary shall
define through rulemaking a limited form of the report
under paragraph (1) required of plan administrators who
are drug manufacturers, drug wholesalers, or other
direct participants in the drug supply chain, in order
to prevent anti-competitive behavior.
``(4) Report to gao.--An entity providing pharmacy benefits
management services on behalf of a group health plan shall
submit to the Comptroller General of the United States each of
the first 4 reports submitted to a plan administrator under
paragraph (1) with respect to such plan, and other such reports
as requested, in accordance with the privacy requirements under
paragraph (2), the disclosure and redisclosure standards under
paragraph (3), the standards specified pursuant to paragraph
(5).
``(5) Standard format.--Not later than 6 months after the
date of enactment of this section, the Secretary shall specify
through rulemaking standards for entities required to submit
reports under paragraph (4) to submit such reports in a
standard format.
``(c) Enforcement.--
``(1) Failure to provide timely information.--An entity
providing pharmacy benefits management services that violates
subsection (a) or fails to provide information required under
subsection (b) shall be subject to a civil monetary penalty in
the amount of $10,000 for each day during which such violation
continues or such information is not disclosed or reported.
``(2) False information.--An entity providing pharmacy
benefits management services that knowingly provides false
information under this section shall be subject to a civil
money penalty in an amount not to exceed $100,000 for each item
of false information. Such civil money penalty shall be in
addition to other penalties as may be prescribed by law.
``(3) Procedure.--The provisions of section 1128A of the
Social Security Act, other than subsection (a) and (b) and the
first sentence of subsection (c)(1) of such section shall apply
to civil monetary penalties under this subsection in the same
manner as such provisions apply to a penalty or proceeding
under section 1128A of the Social Security Act.
``(4) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance with
a requirement of this section, for an entity in violation of
this section that has made a good-faith effort to comply with
this section.
``(d) Rule of Construction.--Nothing in this section shall be
construed to permit a group health plan, or other entity to restrict
disclosure to, or otherwise limit the access of, the Department of the
Treasury to a report described in subsection (b)(1) or information
related to compliance with subsection (a) by such plan or entity.
``(e) Definitions.--In this section:
``(1) Large employer.--The term `large employer' means, in
connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at
least 50 employees on business days during the preceding
calendar year and who employs at least 1 employee on the first
day of the plan year.
``(2) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act.''.
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of the Internal Revenue Code of
1986 is amended by adding at the end the following new item:
``Sec. 9826. Oversight of pharmacy benefits manager services.''.
SEC. 4. INFORMATION ON PRESCRIPTION DRUGS.
(a) In General.--Subpart B of part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et
seq.), as amended by section 3, is further amended by adding at the end
the following new section:
``SEC. 727. INFORMATION ON PRESCRIPTION DRUGS.
``(a) In General.--A group health plan or a health insurance issuer
offering group health insurance coverage shall--
``(1) not restrict, directly or indirectly, any pharmacy
that dispenses a prescription drug to a participant of
beneficiary in the plan or coverage from informing (or penalize
such pharmacy for informing) a participant or beneficiary of
any differential between the participant's or beneficiary's
out-of-pocket cost under the plan or coverage with respect to
acquisition of the drug and the amount an individual would pay
for acquisition of the drug without using any health plan or
health insurance coverage; and
``(2) ensure that any entity that provides pharmacy
benefits management services under a contract with any such
health plan or health insurance coverage does not, with respect
to such plan or coverage, restrict, directly or indirectly, a
pharmacy that dispenses a prescription drug from informing (or
penalize such pharmacy for informing) a participant or
beneficiary of any differential between the participant's or
beneficiary's out-of-pocket cost under the plan or coverage
with respect to acquisition of the drug and the amount an
individual would pay for acquisition of the drug without using
any health plan or health insurance coverage.
``(b) Definition.--For purposes of this section, the term `out-of-
pocket cost', with respect to acquisition of a drug, means the amount
to be paid by the participant or beneficiary under the plan or
coverage, including any cost-sharing (including any deductible,
copayment, or coinsurance) and, as determined by the Secretary, any
other expenditure.''.
(b) Clerical Amendment.--The table of contents in section 1 of the
Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et
seq.), as amended by section 3, is further amended by inserting after
the item relating to section 726 the following new item:
``Sec. 727. Information on prescription drugs.''.
SEC. 5. ADVISORY COMMITTEE ON THE ACCESSIBILITY OF CERTAIN INFORMATION.
(a) In General.--Not later than January 1, 2025, the Secretary of
Labor (in this section referred to as the ``Secretary'') shall convene
an Advisory Committee (in this section referred to as the
``Committee'') consisting of 9 members to advise the Secretary on how
to improve the accessibility and usability of information made
available in accordance the amendments made by section 3 and by section
204 of division BB of the Consolidated Appropriation Act, 2021 (Public
Law 116-260), streamline the reporting of such information, and ensure
that such information fully meets the needs of employers, patients,
researchers, regulators, and purchasers.
(b) Membership.--The Secretary shall appoint members representing
end-users of the information described in subsection (a). Vacancies on
the Committee shall be filled by appointment consistent with this
subsection not later than 3 months after the vacancy arises.
(c) Termination.--The Committee established under this section
shall terminate on January 1, 2028.
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