HR 10549

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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. <all>