[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5197 Introduced in House (IH)]
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119th CONGRESS
1st Session
H. R. 5197
To amend title XVIII of the Social Security Act to limit cost sharing
for drugs under the Medicare program.
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IN THE HOUSE OF REPRESENTATIVES
September 8, 2025
Ms. Malliotakis introduced the following bill; which was referred to
the Committee on Energy and Commerce, and in addition to the Committee
on Ways and Means, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
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A BILL
To amend title XVIII of the Social Security Act to limit cost sharing
for drugs under the Medicare program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Protect Beneficiaries from Middlemen
Act''.
SEC. 2. LIMITATION ON COST SHARING TO NET PRICE AMOUNT UNDER MEDICARE
PART D.
(a) In General.--Section 1860D-2 of the Social Security Act (42
U.S.C. 1395w-102) is amended--
(1) in subsection (b)--
(A) in paragraph (2)(A), by striking ``(8) and
(9)'' and inserting ``(8), (9), and (10)'';
(B) in paragraph (9)(B)(ii), by striking ``For a
plan year'' and inserting ``Subject to paragraph (10),
for a plan year''; and
(C) by adding at the end the following new
paragraph:
``(10) Limitation on cost sharing to net price amount.--
``(A) In general.--For a plan year beginning on or
after January 1, 2027, the coverage provides benefits
for a supply of a covered part D drug dispensed by a
pharmacy, for costs in excess of the deductible
specified in paragraph (1) and prior to an individual
reaching the out-of-pocket threshold under paragraph
(4), with cost-sharing for a month's supply that does
not exceed the average net price for such a supply of
such drug during such plan year (or, if lower, the
applicable cash price for such a supply of such drug so
dispensed by such pharmacy).
``(B) Definitions.--In this paragraph:
``(i) Applicable cash price.--The term
`applicable cash price' means, with respect to
a supply of a covered part D drug dispensed by
a pharmacy, the price that such pharmacy would
charge for such supply of such drug dispensed
to an individual without benefits for such drug
under any Federal health care program (as
defined in section 1128B), a group health plan
or group or individual health insurance
coverage (as such terms are defined in section
2791 of the Public Health Service Act), or the
program established under chapter 89 of title
5, United States Code.
``(ii) Average net price.--The term
`average net price' means, with respect to a
supply of a covered part D drug, a prescription
drug plan, and a plan year, the average amount
paid under such plan (including any amounts
paid by an individual enrolled under such plan
as cost sharing for such drug) as payment for
such a supply of such drug dispensed during
such year, less any rebates or other forms of
remuneration received under such plan with
respect to such drug.''; and
(2) in subsection (c), by adding at the end the following
new paragraph:
``(7) Cost sharing limited to net price.--The coverage is
provided in accordance with subsection (b)(10).''.
(b) Conforming Amendment to Cost-Sharing for Low-Income
Individuals.--Section 1860D-14(a)(1)(D)(iii) of the Social Security Act
(42 U.S.C. 1395w-114(a)(1)(D)(iii)) is amended by adding at the end the
following new sentence: ``For plan year 2027 and subsequent plan years,
the copayment amount applicable under this clause to a supply of a
covered part D drug dispensed to the individual may not exceed the
amount provided under section 1860D-2(b)(10).''.
(c) GAO Report.--Not later than January 1, 2029, the Comptroller
General of the United States shall submit to Congress a report
containing--
(1) an analysis of compliance with the amendments made by
this section;
(2) an analysis of enforcement of such amendments;
(3) recommendations with respect to improving such
enforcement; and
(4) recommendations relating to improving public
disclosure, and public awareness of, the requirements of such
amendments.
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