H.R. 10133: Fair Prescription Pricing Act of 2026
This bill is not yet law.
It is still working its way through Congress and its contents may change.
Plain-language summary
The Fair Prescription Pricing Act of 2026 establishes a cap on out-of-pocket prescription drug expenses for individuals enrolled in private health insurance. Under the bill, health plans cannot impose cost-sharing amounts for covered outpatient drugs dispensed by in-network pharmacies that exceed the nationwide average consumer purchase price over the preceding year. This limitation applies across group health plans, individual market policies, and employer-sponsored coverage subject to federal oversight. The legislation enforces these requirements by amending key health and tax statutes governing health insurance issuers and pharmacy benefit managers.
Potential impact: Insured individuals with high-deductible or coinsurance-heavy plans would be protected from paying more than the national retail average for in-network outpatient medications. Health insurance issuers and pharmacy benefit managers (PBMs) would face new regulatory compliance requirements to track national price benchmark surveys and cap enrollee cost-sharing accordingly.
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Bill Highlights
- Amends Part D of title XXVII of the Public Health Service Act by adding section 2799A-12, prohibiting group health plans and health insurance issuers in the individual and group markets from charging cost sharing for covered outpatient drugs dispensed by in-network pharmacies in excess of the nationwide average consumer purchase price over the preceding one-year period.
- Amends the Employee Retirement Income Security Act of 1974 (ERISA) by adding section 727 to apply the consumer purchase price cost-sharing cap to employer-sponsored group health plans and group coverage.
- Amends subchapter B of chapter 100 of the Internal Revenue Code of 1986 by adding section 9827 to extend the cost-sharing limitation to group health plans under federal tax code requirements.
- Mandates that the cost-sharing ceiling applies comprehensively to all forms of enrollee out-of-pocket costs, explicitly including deductibles, coinsurance, and copayments.
- Establishes that the benchmark for the nationwide average consumer purchase price must be derived using survey data described under section 1927(f)(1)(A)(i) of the Social Security Act (Medicaid drug pricing surveys).
- Clarifies that these prescription drug cost-sharing restrictions directly apply to the administration of benefits by pharmacy benefit managers (PBMs) acting on behalf of covered health plans.
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Positions on this bill
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Hillary Scholten
D-MI · Dist. 3