# Patients Before Middlemen Act

This bill aims to reduce the power of pharmacy benefit managers (PBMs)—the companies that sit between patients, doctors, pharmacies, and insurance companies to decide which drugs are covered and how much they cost. Right now, PBMs control a huge portion of the prescription drug market and make decisions that can dramatically affect what medications people can afford and access. This bill would give patients and doctors more say in those decisions and make PBMs more transparent about how they operate.

The main changes would require PBMs to be more open about their pricing practices and the deals they make with drug manufacturers and pharmacies. Currently, much of this happens behind closed doors, which can lead to situations where patients pay high prices even when cheaper alternatives exist. The bill would also limit PBMs' ability to steer patients toward expensive drugs and would require them to pass along savings from manufacturers directly to patients at the pharmacy counter, rather than keeping those savings for themselves. Additionally, it would make it easier for patients to use their preferred pharmacy instead of being forced to use the PBM's preferred network.

Who this affects most: People with insurance who take prescription medications, especially those with chronic conditions who need multiple drugs. Patients who struggle with high copays or can't afford their medications would potentially benefit if PBMs are forced to pass savings along. Small and independent pharmacies could also benefit by having more ability to compete with large pharmacy chains. On the other side, PBMs and some large pharmacy chains might see their profits decrease, which could eventually affect insurance premiums—though supporters argue that increased competition and transparency would ultimately lower costs for everyone.

Patients Before Middlemen Act

Blackburn, Marsha

Patients Before Middlemen ActThis bill establishes certain standards and reporting requirements for prescription drug plan (PDP) sponsors, pharmacy benefit managers (PBMs), and pharmacies under the Medicare prescription drug benefit and Medicare Advantage.Specifically, the Centers for Medicare &amp; Medicaid Services (CMS) must develop reasonable and relevant standards for contracts between PDP sponsors and pharmacies. The CMS must seek input from interested stakeholders when developing these standards. PDP sponsors are subject to civil penalties for violating these standards; PBMs must reimburse PDP sponsors for civil penalties that result from their responsibilities.The bill also requires the CMS to report periodically on essential retail pharmacies (i.e., pharmacies that serve as the only pharmacy within a certain radius) with respect to costs, contracts, and other specified information, particularly in relation to other types of pharmacies.Additionally, PBMs may not receive any income other than flat, bona fide service fees. PBMs must turn over any excess amounts they receive to PDP sponsors; PDP sponsors must turn over these amounts to the CMS. In addition, PBMs must report to PDP sponsors and to the CMS an itemized list of prescription drugs that were dispensed during the previous year and related data about costs, claims, affiliated pharmacies, and other specified information. PDP sponsors may audit PBMs to ensure compliance with these requirements and must annually certify their compliance; PBMs are responsible for any associated civil penalties for violations.The bill's changes generally apply beginning in 2028.