Patients Choice in Specialty Pharmacy Act
- Sponsor
- Rep. Dunn, Neal P. [R-FL-2]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Sep 24, 2026
Bottom line
The bill aims to enhance patient choice and foster competition in the specialty pharmacy market by preventing health plans from favoring their own or affiliated pharmacies.
What it actually does
This bill amends the Public Health Service Act to prohibit group health plans and health insurance issuers from requiring, steering, or inducing enrollees to obtain specialty prescription drugs from an affiliated specialty pharmacy. It also prevents these plans from excluding qualified non-affiliated specialty pharmacies from their networks if they meet certain licensing, accreditation, and reimbursement criteria.
Proponents argue
Supporters argue this bill empowers patients by giving them more control over where they obtain critical specialty medications, fostering competition, and potentially lowering costs by preventing anticompetitive practices by health plans and their pharmacy benefit managers (PBMs). It ensures access to a wider range of pharmacies that may offer specialized services and support.
Opponents contend
Opponents, likely health plans and PBMs, might argue that these practices are necessary for cost control, quality assurance, and integrated care management. They may contend that restricting their ability to manage pharmacy networks could lead to higher drug costs, reduced efficiency, and fragmentation of care, ultimately harming patients and increasing premiums.
The bill is short and relatively straightforward, making it accessible for an informed reader to understand its core provisions within a reasonable timeframe.
Section 2(a), adding new Section 2730(a) to the Public Health Service Act
Prohibition on Steering to Affiliated Specialty Pharmacies
This provision prevents group health plans and health insurance issuers from forcing or encouraging patients to use a specialty pharmacy that is owned by or closely connected to the health plan or its pharmacy benefit manager. They cannot impose higher cost-sharing, offer financial incentives, or create administrative burdens for patients who choose an independent specialty pharmacy.
Supporters argue
Supporters argue this provision protects patient autonomy and ensures fair competition by preventing health plans from leveraging their market power to benefit their own business interests at the expense of patient choice and independent pharmacies.
Critics contend
Opponents (health plans/PBMs) may argue that steering patients to affiliated pharmacies allows for better care coordination, quality control, and cost management through integrated systems and negotiated discounts, and that this prohibition could disrupt these benefits.
Tradeoffs
This provision balances patient choice and independent pharmacy competition against health plans' desire for integrated care models and potential cost efficiencies through affiliated networks.
Section 2(a), adding new Section 2730(b) to the Public Health Service Act
Ensuring Network Access for Qualified Specialty Pharmacies
This section requires health plans and insurers to include any specialty pharmacy in their network if that pharmacy is licensed, in good standing, agrees to the plan's standard terms and reimbursement rates, and potentially holds national accreditation. Exceptions are allowed for pharmacies involved in fraud or posing an imminent risk of patient harm.
Section 2(a), adding new Section 2730(c) to the Public Health Service Act
Defining Key Terms for Specialty Pharmacy Regulation
This section defines 'affiliated specialty pharmacy' as one where the health plan or its PBM has an ownership, control, or managerial interest. It also defines 'nationally recognized accrediting organization' (listing specific bodies like the Joint Commission) and 'specialty pharmacy' based on the types of drugs dispensed and the support services provided.
The bill explicitly states that its prohibitions on steering and network exclusion do not apply to 'self-insured group health plans.'
Section 2(a), new Section 2730(a) and (b) (parenthetical exclusion)
Why it matters:This is standard legislative practice, reflecting the jurisdictional limitations of the Public Health Service Act, which generally regulates fully-insured plans, while self-insured plans are primarily regulated by ERISA. It's not necessarily evasive but is a critical carve-out.
Case for: Supporters of this carve-out would argue it respects the existing regulatory framework, where self-insured plans are governed by ERISA, and avoids creating conflicting or overlapping regulations.
Case against: Critics might argue that excluding self-insured plans significantly limits the bill's reach, as a large portion of the insured population is covered by such plans, potentially leaving many patients without the protections intended by the bill.
Estimated impact: This exclusion means a substantial portion of the commercially insured population (estimated over 60% of covered workers) would not be covered by these new protections, limiting the bill's overall impact on patient choice and competition.