Transparency in Coverage Act

This bill amends the Employee Retirement Income Security Act of 1974 (ERISA) to increase transparency in health coverage and reform pharmacy benefit management for group health plans.

Sec. 2, Promoting group health plan and group health insurance coverage price transparency: This section requires group health plans and insurers to publicly disclose claims policies, financial data, enrollment, denied claims, rating practices, out-of-network cost-sharing, participant rights, and rate/payment information. Rate/payment info must be public by Jan 10, 2025, and monthly thereafter, with real-time access via an API by Jan 1, 2027. Plans must provide participants, upon request, a cost-sharing estimate for a specific item or service, including in-network rates, allowed amounts for out-of-network providers, deductible accumulations, and prior authorization requirements, via a self-service tool or paper/phone disclosure. Plans must also let providers learn a patient's cost-sharing with consent. Rate/payment info includes in-network rates for items/services and drugs, and average amounts paid for drugs net of rebates.

Sec. 3, Pharmacy benefit manager transparency: For plan years starting on or after Jan 1, 2025, group health plans and pharmacy benefit managers (PBMs) cannot enter contracts that limit disclosure of info needed for quarterly reports to plan administrators. Reports must include copay assistance dollars, gross and net drug spending, rebates and fees received, payments for business referrals, details on affiliated pharmacy use (including drug-level charges and comparisons to other network pharmacies), and for large employers, a list of each drug with claims data, out-of-pocket spending, and therapeutic class information including rebates and net spending.

Sec. 4, Information on prescription drugs: Group health plans and insurers cannot restrict a pharmacy from telling a participant about the difference between their out-of-pocket cost under the plan and the cash price for a drug, and must ensure PBMs do not restrict such communication.

Sec. 5, Advisory Committee on the accessibility of certain information: By Jan 1, 2025, the Secretary of Labor must convene a 9-member advisory committee to advise on improving the accessibility and usability of information from the PBM transparency reports and other related provisions. The committee will terminate on Jan 1, 2028.