H.R. 5197 — Protect Beneficiaries from Middlemen Act

This section requires Medicare Part D prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans to limit enrollee cost-sharing for a month's supply of a covered Part D drug—after the deductible and before the out-of-pocket threshold—to the average net price under the plan for the plan year (or, if lower, the applicable cash price charged by the dispensing pharmacy without regard to insurance) for plan years beginning on or after January 1, 2027. (Average net price is the average amount paid by the plan, including enrollee cost-sharing, less rebates and other remuneration; applicable cash price excludes payments from federal health care programs, group or individual health coverage, or the Federal Employees Health Benefits program.) This section further limits copayments under the low-income subsidy program to the same amount for plan year 2027 and subsequent years and directs the Government Accountability Office (GAO) to submit a report to Congress by January 1, 2029, analyzing compliance and enforcement of these requirements and providing related recommendations. (Thus, this caps Part D beneficiary cost-sharing in the initial coverage phase at the plan's net drug acquisition cost, potentially reducing out-of-pocket expenses.)