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[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10549 Introduced in House (IH)]
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119th CONGRESS
2d Session
H. R. 10549
To amend title XXVII of the Public Health Service Act to prohibit
certain group health plans and health insurance issuers from limiting
choice in specialty pharmacies.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 24, 2026
Mr. Dunn of Florida (for himself and Mr. Wilson of South Carolina)
introduced the following bill; which was referred to the Committee on
Energy and Commerce
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act to prohibit
certain group health plans and health insurance issuers from limiting
choice in specialty pharmacies.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Patients Choice in Specialty
Pharmacy Act''.
SEC. 2. PROHIBITING CERTAIN GROUP HEALTH PLANS AND HEALTH INSURANCE
ISSUERS FROM LIMITING CHOICE IN SPECIALTY PHARMACIES.
(a) In General.--Subpart II of part A of title XXVII of the Public
Health Service Act (42 U.S.C. 300gg-11 et seq.) is amended by adding at
the end the following new section:
``SEC. 2730. PROHIBITION ON LIMITING SPECIALTY PHARMACY CHOICE.
``(a) Prohibition on Steering to Affiliated Specialty Pharmacies.--
A group health plan (other than a self-insured group health plan) or a
health insurance issuer offering group or individual health insurance
coverage may not require, steer, or induce an enrollee in the plan or
coverage to obtain a prescription drug for which benefits are available
under the plan or coverage from an affiliated specialty pharmacy,
including by--
``(1) imposing higher cost sharing, including copayments,
coinsurance, or deductibles, when such drug is dispensed by a
specialty pharmacy that is not an affiliated specialty
pharmacy;
``(2) offering a discount, rebate, or other financial
incentive that is conditioned on the enrollee obtaining such
drug from an affiliated specialty pharmacy; or
``(3) imposing a penalty, delay, or other administrative
burden on an enrollee (or the health care provider prescribing
such drug to such enrollee) who obtains (or directs such
enrollee to obtain) such drug from a specialty pharmacy that is
not an affiliated specialty pharmacy.
``(b) Limitation on Excluding Qualified Specialty Pharmacies From
Network.--
``(1) In general.--Subject to paragraph (2), a group health
plan (other than a self-insured group health plan) or a health
insurance issuer offering group or individual health insurance
coverage may not refuse to contract with, or otherwise exclude
from the network of the plan or coverage, any specialty
pharmacy that--
``(A) is licensed and in good standing under the
laws of the State in which it dispenses the drug;
``(B) agrees to meet all terms and conditions of
network participation that are uniformly applied to all
specialty pharmacies in the network of the plan or
coverage, which may include, at the option of the plan
or issuer, a requirement that the specialty pharmacy
maintain accreditation from a nationally recognized
accrediting organization; and
``(C) is willing to accept the same reimbursement
rates as other specialty pharmacies in the network of
the plan or coverage.
``(2) Exclusion allowed for good cause.--The requirement
under paragraph (1) shall not apply with respect to a group
health plan (other than a self-insured group health plan) or a
health insurance issuer offering group or individual health
insurance coverage and a specialty pharmacy in the case that--
``(A) such specialty pharmacy--
``(i) has been convicted under Federal or
State law of an offense related to fraud or
abuse; or
``(ii) has been subjected to disciplinary
action by a State board of pharmacy in
connection with activities related to fraud or
abuse;
``(B) such specialty pharmacy has been excluded or
suspended from participation in the Medicare program
under title XVIII of the Social Security Act, or a
State health care program (as defined in section
1128(h) of such Act); or
``(C) the plan or issuer demonstrates to the State
board of pharmacy or other competent regulatory
authority that contracting with such specialty pharmacy
poses an imminent risk of patient harm.
``(c) Definitions.--In this section:
``(1) Affiliated specialty pharmacy.--The term `affiliated
specialty pharmacy' means, with respect to a group health plan
(other than a self-insured group health plan) or a health
insurance issuer offering group or individual health insurance
coverage, a specialty pharmacy--
``(A) with respect to which such plan or issuer (or
an entity providing pharmacy benefit management
services on behalf of such plan or issuer) is a person
with an ownership or control interest (as defined in
section 1124(a)(3) of the Social Security Act); or
``(B) with respect to which such plan or issuer (or
an entity providing pharmacy benefit management
services on behalf of such plan or issuer) otherwise
exercises (directly or indirectly) operational,
financial, or managerial control.
``(2) Nationally recognized accrediting organization.--The
term `nationally recognized accrediting organization' means--
``(A) the Joint Commission on Health Care
Organizations;
``(B) the Utilization Review Accreditation
Commission; or
``(C) the Accreditation Commission for Health Care.
``(3) Specialty pharmacy.--The term `specialty pharmacy'
means a pharmacy that--
``(A) is licensed and in good standing under the
laws of the State in which it dispenses drugs;
``(B) dispenses drugs that--
``(i) require handling, storage,
administration, or monitoring exceeding that
customarily required for most retail
prescription drugs; or
``(ii) are used in the treatment of
complex, expensive, or rare health conditions;
and
``(C) has the capability, consistent with
applicable State law, to provide clinical and patient
support services appropriate to the dispensing of drugs
described in subparagraph (B), which may include
patient education, adherence support, care coordination
with the prescribing provider, and monitoring for
adverse events.''.
(b) Effective Date.--The amendments made by this section shall
apply with respect to plan years beginning on or after January 1, 2029.
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