Protect Beneficiaries from Middlemen Act
The Protect Beneficiaries from Middlemen Act would overhaul how Medicare Part D plans determine patient cost sharing for covered drugs. Starting with plan years beginning in 2027, the Act would cap a beneficiary’s monthly cost-sharing amount for a Part D drug at the drug’s net price (or, if lower, the applicable cash price) rather than the current cost-sharing levels that can be influenced by rebates and middlemen. Net price is defined as the price paid by the plan for the drug (including the beneficiary’s cost sharing), minus rebates or other remuneration received by the plan. The bill also requires that low-income copayments for Part D drugs not exceed this net price cap and creates a GAO evaluation to assess compliance, enforcement, and transparency. In short, the bill seeks to reduce or cap out-of-pocket costs for Part D beneficiaries by tying cost sharing to the actual net price paid by the plan, and it imposes oversight and future reporting to Congress on how well the approach is working and how to improve it.
Key Points
- 1Establishes a new limit on Part D cost sharing: for plan years beginning on or after January 1, 2027, a month’s supply of a covered Part D drug dispensed by a pharmacy cannot have cost sharing higher than the plan’s average net price for that drug (or the lower applicable cash price), prior to reaching the out-of-pocket threshold.
- 2Net price and cash price definitions:
- 3- Applicable cash price: the price a pharmacy would charge a person without health coverage under federal programs or other specified coverage.
- 4- Average net price: the average amount paid under the plan for a drug (including member cost sharing) minus rebates or other remuneration the plan receives for that drug.
- 5Conforming change for low-income beneficiaries: for plan year 2027 and later, the copayment for a covered Part D drug for low-income individuals cannot exceed the net price cap.
- 6GAO oversight: requires a GAO report by January 1, 2029 analyzing compliance, enforcement, and recommendations for better enforcement and public disclosure.
- 7Scope within Part D: the cost-sharing cap applies to a supply dispensed by a pharmacy and is designed to function within the existing deductible and out-of-pocket thresholds of Part D.