Ensuring Seniors Access to Local Pharmacies Act of 2021

I 117TH CONGRESS 1ST SESSION H. R. 2608 To amend title XVIII of the Social Security Act to ensure equal access of Medicare beneficiaries to community pharmacies in underserved areas as network pharmacies under Medicare prescription drug coverage, and for other purposes. IN THE HOUSE OF REPRESENTATIVES APRIL 15, 2021 Mr. WELCH (for himself, Mr. GRIFFITH, Mr. VICENTE GONZALEZ of Texas, Mr. CRAWFORD, Mr. CARTER of Georgia, Mrs. AXNE, Mr. ALLEN, Mr. RUPPERSBERGER, and Mr. WESTERMAN) 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 subse- quently 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 title XVIII of the Social Security Act to ensure equal access of Medicare beneficiaries to community pharmacies in underserved areas as network pharmacies under Medicare prescription drug coverage, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Ensuring Seniors Ac- 4 cess to Local Pharmacies Act of 2021’’. 5 VerDate Sep 11 2014 23:44 Jun 01, 2021 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H2608.IH H2608 kjohnson on DSK79L0C42PROD with BILLS 2 •HR 2608 IH SEC. 2. ALLOWING ANY STATE LICENSED PHARMACY SERV- 1 ING AN UNDERSERVED AREA TO BECOME A 2 NETWORK PHARMACY UNDER MEDICARE 3 PRESCRIPTION DRUG COVERAGE. 4 (a) IN GENERAL.—Section 1860D–4(b)(1)(B) of the 5 Social Security Act (42 U.S.C. 1395w–104(b)(1)(B)) is 6 amended— 7 (1) by striking ‘‘DISCOUNTS ALLOWED FOR 8 NETWORK PHARMACIES.—For’’ and inserting the 9 following: ‘‘DISCOUNTS ALLOWED FOR NETWORK 10 PHARMACIES.— 11 ‘‘(i) IN GENERAL.—For’’; and 12 (2) by adding at the end the following new 13 clause: 14 ‘‘(ii) INCLUSION OF PHARMACIES LO- 15 CATED IN UNDERSERVED AREAS IN NET- 16 WORKS.—For plan years beginning on or 17 after January 1, 2022, in the case of a 18 prescription drug plan that has, in its net- 19 work of pharmacies, one or more phar- 20 macies located in a health professional 21 shortage area (as defined in section 22 332(a)(1)(A) of the Public Health Service 23 Act), in a medically underserved area (ac- 24 cording to a designation under section 25 330(b)(3)(A) of the Public Health Service 26 VerDate Sep 11 2014 23:44 Jun 01, 2021 Jkt 019200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H2608.IH H2608 kjohnson on DSK79L0C42PROD with BILLS 3 •HR 2608 IH Act), among a medically underserved popu- 1 lation (as defined in such section 2 330(b)(3)(A) of such Act), or in a rural 3 area (as defined by the Federal Office of 4 Rural Health Policy), and that provides a 5 reduction in coinsurance or copayments de- 6 scribed in clause (i) for covered part D 7 drugs dispensed through such pharmacies, 8 such plan shall extend to any pharmacy lo- 9 cated in such area or among such popu- 10 lation the option to be an in-network phar- 11 macy with respect to such plan under 12 terms and conditions (including the reduc- 13 tions described in clause (i)) comparable to 14 those the plan has agreed upon with other 15 in-network pharmacies located in such area 16 or among such population.’’. 17 SEC. 3. REASONABLE REIMBURSEMENT REQUIREMENTS. 18 Section 1860D–2(d)(1)(B) of the Social Security Act 19 (42 U.S.C. 1395w–102(d)(1)(B)) is amended— 20 (1) by striking ‘‘PRICES.—For purposes’’ and 21 inserting ‘‘PRICES.— 22 ‘‘(i) IN GENERAL.—For purposes’’; 23 and 24 VerDate Sep 11 2014 23:44 Jun 01, 2021 Jkt 019200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2608.IH H2608 kjohnson on DSK79L0C42PROD with BILLS 4 •HR 2608 IH (2) by adding at the end the following new 1 clauses: 2 ‘‘(ii) REASONABLE REIMBURSE- 3 MENT.—For plan years beginning on or 4 after January 1, 2022, a PDP sponsor and 5 a Medicare Advantage organization shall 6 ensure that— 7 ‘‘(I) each prescription drug plan 8 or MA–PD plan offered by the spon- 9 sor or organization does not reimburse 10 a pharmacy or pharmacist an amount 11 less than the amount that the phar- 12 macy benefits manager reimburses a 13 pharmacy benefits manager affiliate 14 (as defined in clause (iv)); and 15 ‘‘(II) in no case may the nego- 16 tiated price for a covered part D drug 17 furnished by a pharmacy under a pre- 18 scription drug plan or MA–PD plan 19 offered by the sponsor or organiza- 20 tion, be less than such pharmacy’s 21 cost of purchasing and dispensing 22 such drug and providing such other 23 services associated with furnishing 24 VerDate Sep 11 2014 23:44 Jun 01, 2021 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2608.IH H2608 kjohnson on DSK79L0C42PROD with BILLS 5 •HR 2608 IH such drug as may be specified by the 1 Secretary. 2 ‘‘(iii) CLAIM REIMBURSEMENT DIS- 3 CLOSURE REQUIREMENTS.—With respect 4 to payment made by a PDP sponsor or a 5 Medicare Advantage organization to a 6 pharmacy for a covered part D drug fur- 7 nished by such pharmacy during a plan 8 year beginning on or after January 1, 9 2022, such sponsor or organization shall 10 promptly furnish all pricing components 11 including the Network Reimbursement ID 12 used to price the claim, any fees, pharmacy 13 price concessions, discounts, subsidies, re- 14 bates, incentives, or any other forms of di- 15 rect or indirect remuneration that affect 16 payment and pricing of the claim as part 17 of the claim adjudication response at the 18 point-of sale. All pricing components de- 19 scribed in the preceding sentence shall 20 each be identified in a predetermined line 21 item in the remittance advice that is stand- 22 ard across the industry. The PDP sponsor 23 or Medicare Advantage organization shall 24 include suitable claim-level detail on the 25 VerDate Sep 11 2014 23:44 Jun 01, 2021 Jkt 019200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2608.IH H2608 kjohnson on DSK79L0C42PROD with BILLS 6 •HR 2608 IH electronic remittance advice that accom- 1 panies each payment. This claim-level de- 2 tail shall include, in an industry standard- 3 ized format, all fields needed to properly 4 identify the claim, including the Claim Au- 5 thorization Number, date of service, date 6 of payment remittance, ingredient cost re- 7 imbursed, dispensing fee reimbursed, pay- 8 ment amounts including the Network ID 9 used to price the claim, the specific dollar 10 amounts and the appropriate qualifier 11 codes for each payment adjustment includ- 12 ing fees, pharmacy price concessions, or in- 13 centives. 14 ‘‘(iv) PHARMACY BENEFITS MANAGER 15 AFFILIATE DEFINED.—For purposes of 16 clause (ii), the term ‘pharmacy benefits 17 manager affiliate’ means a pharmacy or 18 pharmacist that directly or indirectly, 19 through one or more intermediaries, owns 20 or controls, is owned or controlled by, or is 21 under common ownership or corporate con- 22 trol with a pharmacy benefits manager, 23 VerDate Sep 11 2014 23:44 Jun 01, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2608.IH H2608 kjohnson on DSK79L0C42PROD with BILLS 7 •HR 2608 IH PDP sponsor or a Medicare Advantage or- 1 ganization.’’. 2 Æ VerDate Sep 11 2014 23:44 Jun 01, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6301 E:\BILLS\H2608.IH H2608 kjohnson on DSK79L0C42PROD with BILLS