H.R.5234 - PBM Audit Reform and Transparency Act of 2010111th Congress (2009-2010)
Summary: H.R.5234 — 111th Congress (2009-2010)
Introduced in House (05/06/2010)
PBM Audit Reform and Transparency Act of 2010 - Amends the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), the Internal Revenue Code, and part D (Voluntary Prescription Drug Benefit Program) of title XVIII (Medicare) of the Social Security Act to prohibit a group health plan from entering into a contract with any pharmacy benefit manager (PBM) to manage the prescription drug coverage provided under the plan, or to control the costs of such coverage, unless the PBM satisfies the following requirements.
Requires the PBM to report at least annually to each plan, including regarding the PBM's payments to pharmacies, payments received by the PBM from plans and drug manufacturers, and information on generic drugs.
Sets forth provisions governing the interaction between a PBM and pharmacies that contract with the PBM, including: (1) requiring the PBM to disclose reimbursement information; (2) requiring prompt payment for clean claims; (3) prohibiting the exclusion of qualified pharmacies from participation in a network; and (4) requiring a pharmacy owner to sign a contract with a PBM before assuming responsibility to participate in a network managed by the PBM.
Prohibits a PBM from requiring or offering incentives to a beneficiary to fill a prescription at a pharmacy that the PBM has an ownership interest in or at a pharmacy with an ownership interest in the PBM.
Sets forth requirements for PBM audits of a contract pharmacy, including requirements for prior written notice and an appeals process.
Establishes limitations on a PBM seeking to sell, lease, or rent utilization or claims data that a PBM possesses as a result of a contract with a health plan, including requiring a PBM to: (1) provide prior notification of, and receive written approval from, the plan; and (2) provide an opportunity for covered individuals to opt-out of a sale, leasing, or renting of data related to such individual. Prohibits a PBM from directly contacting a covered individual without express written permission of the plan and the individual. Limits data sharing with PBM-owned pharmacies or pharmacies with ownership interests in the PBM.
Applies the provisions of this Act to health insurance coverage offered in the individual market.