H.R. 6610 — Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]

This section establishes pharmacy payment and reimbursement requirements for health benefits plans under the Federal Employees Health Benefits Program (FEHB) by adding a new subsection (c) to 5 U.S.C. §8904. Specifically, the Office of Personnel Management (OPM) may not contract for or approve any such plan unless it (1) requires pharmacy benefits managers (PBMs) to reimburse in-network pharmacies for a prescription drug's ingredient cost at the national average drug acquisition cost (NADAC) on the day of claim adjudication (or wholesale acquisition cost if not listed on NADAC) plus the lesser of 4% of that amount or $50, pay a professional dispensing fee equal to the state's Medicaid dispensing fee under title XIX of the Social Security Act, and for any manufacturer rebate received, apply a point-of-sale reduction to enrollee coinsurance or copayment based on the drug's net cost (including the rebate) and remit the remainder to the plan carrier; (2) prohibits PBMs from directing or steering enrollees to specific (including affiliated) pharmacies, preferentially advertising or promoting them, excluding or restricting in-network pharmacies through network design or practices, influencing drug manufacturers to limit distribution to certain pharmacies, or recouping or increasing enrollee costs to offset dispensing fees; (3) bars PBMs from reducing pharmacy reimbursements through claim adjustments, post-adjudication changes, or non-claim-related fees; and (4) requires plan carriers to cooperate with OPM inspections. (Thus, these rules promote fair pharmacy reimbursement, rebate pass-through to FEHB enrollees at the point of sale, and prevention of PBM steering or exclusionary practices.) The subsection also defines key terms, including "affiliate," "in-network pharmacy," "pharmacy benefits manager," and "pharmacy benefits management services."