PBM Price Transparency and Accountability Act

This bill amends the Social Security Act to improve payment accuracy to pharmacies under Medicaid, prevent abusive spread pricing, and ensure pharmacy access and choice for Medicare beneficiaries while modernizing pharmacy benefit manager (PBM) accountability under Medicare.

Sec. 2, Ensuring accurate payments to pharmacies under Medicaid and preventing abusive spread pricing in Medicaid: The bill requires the Secretary of Health and Human Services to conduct monthly surveys of retail community pharmacies and applicable non-retail pharmacies (like mail-order and specialty pharmacies) to determine national average drug acquisition costs, net of all discounts and rebates. States must require pharmacies to respond to these surveys, with civil money penalties up to $100,000 per violation for non-compliance or false information. The Inspector General must conduct periodic studies on survey data, with $5 million appropriated for fiscal year 2026. It also defines "applicable non-retail pharmacy" and "affiliate" and sets effective dates: retail pharmacy survey requirements start 6 months after enactment, while non-retail pharmacy requirements start 18 months after enactment. The Secretary must publish guidance by January 1, 2027, identifying applicable non-retail pharmacies.

Sec. 3, Assuring pharmacy access and choice for Medicare beneficiaries and modernizing and ensuring PBM accountability under Medicare: For plan years starting on or after January 1, 2028, Medicare Part D plan sponsors must permit any willing pharmacy that meets standard contract terms to participate as a network pharmacy. The Secretary must establish standards for reasonable and relevant contract terms by April 2027, after issuing a request for information by April 2026. The bill also requires the Secretary to publish biennial reports through 2034 on trends in payments, fees, and pharmacy participation for "essential retail pharmacies" (those in rural, suburban, or urban areas with no other pharmacy within 10, 2, or 1 mile, respectively, and not affiliates of the plan sponsor or PBM). The Secretary must publish a list of essential retail pharmacies for each plan year starting 2028. Additionally, by January 1, 2028, the Secretary must establish a process for pharmacies to submit allegations of violations of contract standards, with protections against retaliation or coercion by plan sponsors.