Section 1 Short title
This Act may be cited as the “Patient Right to Shop Act”.
Patient Right to Shop Act
A BILL
To prohibit group health plans and health insurance issuers from entering into contracts that would prevent or restrict patient access to drug pricing information otherwise available through consumer decision-support tools.
Sec. 2 Prohibition on blocking consumer decision-support tools
PHSA— Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–111 et seq.) is amended by adding at the end the following:
“2799A–11. Prohibition on blocking consumer decision-support tools
“(a) In general—A group health plan or a health insurance issuer offering group or individual health insurance coverage shall not enter into a contract with an entity that provides pharmacy benefit management services with respect to such plan or coverage if such contract—
“(1) includes any terms, conditions, or costs that would prevent or restrict a third party who is in contract with the plan or issuer to provide a consumer decision-support tool from using relevant information regarding prescription drug benefits under the plan or coverage that are administered by the entity providing pharmacy benefit management services in contract with the plan or issuer; or
“(2) fails to clearly state that the entity providing pharmacy benefit management services is required to provide data required under paragraph (1) in machine readable format for the operability, implementation, and utilization of any such consumer decision-support tool at no cost (direct or indirect) to the group health plan, health insurance issuer, or the third party providing such consumer decision support.
“(b) Consumer decision-Support tool—In this section, the term consumer decision-support tool means a tool designed to inform enrollees in a group health plan or health insurance coverage about all costs for prescription drugs covered by the plan or coverage, including out-of-pocket, copayment, and coinsurance responsibility, as well as additional savings opportunities through other channels such as manufacturer copayment assistance, cash price, and mail order pharmacy benefits.”
ERISA—
In general— Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following:
“726. Prohibition on blocking consumer decision-support tools
“(a) In general—A group health plan or a health insurance issuer offering group health insurance coverage shall not enter into a contract with an entity that provides pharmacy benefit management services with respect to such plan or coverage if such contract—
“(1) includes any terms, conditions, or costs that would prevent or restrict a third party who is in contract with the plan or issuer to provide a consumer decision-support tool from using relevant information regarding prescription drug benefits under the plan or coverage that are administered by the entity providing pharmacy benefit management services in contract with the plan or issuer; or
“(2) fails to clearly state that the entity providing pharmacy benefit management services is required to provide data required under paragraph (1) in machine readable format for the operability, implementation, and utilization of any such consumer decision-support tool at no cost (direct or indirect) to the group health plan, health insurance issuer, or the third party providing such consumer decision support.
“(b) Consumer decision-Support tool—In this section, the term consumer decision-support tool means a tool designed to inform participants and beneficiaries in a group health plan or health insurance coverage about all costs for prescription drugs covered by the plan or coverage, including out-of-pocket, copayment, and coinsurance responsibility, as well as additional savings opportunities through other channels such as manufacturer copayment assistance, cash price, and mail order pharmacy benefits.”
Clerical amendment— The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.) is amended by inserting after the item relating to section 725 the following:
Internal Revenue Code—
In general— Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:
“9826. Prohibition on blocking consumer decision-support tools
“(a) In general—A group health plan offering group health insurance coverage shall not enter into a contract with an entity that provides pharmacy benefit management services with respect to such plan if such contract—
“(1) includes any terms, conditions, or costs that would prevent or restrict a third party who is in contract with the plan to provide a consumer decision-support tool from using relevant information regarding prescription drug benefits under the plan that are administered by the entity providing pharmacy benefit management services in contract with the plan; or
“(2) fails to clearly state that the entity providing pharmacy benefit management services is required to provide data required under paragraph (1) in machine readable format for the operability, implementation, and utilization of any such consumer decision-support tool at no cost (direct or indirect) to the group health plan or the third party providing such consumer decision support.
“(b) Consumer decision-Support tool—In this section, the term consumer decision-support tool means a tool designed to inform participants and beneficiaries in a group health plan about all costs for prescription drugs covered by the plan, including out-of-pocket, copayment, and coinsurance responsibility, as well as additional savings opportunities through other channels such as manufacturer copayment assistance, cash price, and mail order pharmacy benefits.”
Clerical amendment— The table of sections for subchapter B of chapter 100 of such Code is amended by adding at the end the following new item:
Application— The amendments made by subsections (a), (b), and (c) shall apply with respect to plan years beginning on or after the date that is 2 years after the date of enactment of this Act.
Regulations— The Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury shall jointly promulgate regulations to carry out the amendments made by subsections (a), (b), and (c), and shall issue draft regulations not later than 1 year after the date of enactment of this Act.