Rx ACCESS Act
- Sponsor
- Rep. Kiggans, Jennifer A. [R-VA-2]
- Committees
- Armed Services Committee (primary)
- Last action
- Dec 3, 2025
Bottom line
The Rx ACCESS Act seeks to increase TRICARE beneficiary choice and ensure fairer compensation and transparency for retail pharmacies by regulating PBM practices and mandating federal oversight.
What it actually does
This bill aims to reform the TRICARE pharmacy benefits program by enhancing beneficiary choice for non-generic maintenance medications, establishing minimum reimbursement standards for retail pharmacies, and prohibiting certain fees imposed by Pharmacy Benefit Managers (PBMs). It also mandates annual audits by the Comptroller General on PBM reimbursement rates, price concessions, and the adequacy of the TRICARE retail pharmacy network to ensure beneficiary access and choice.
Proponents argue
Supporters argue this bill will improve access to essential medications for military families and retirees by empowering beneficiaries to choose their preferred pharmacy and ensuring that local retail pharmacies can afford to participate in the TRICARE network. They contend that current PBM practices, including low reimbursement rates and hidden fees, threaten the viability of independent pharmacies and limit beneficiary access, especially in rural areas. This bill promotes fairness and transparency in the TRICARE pharmacy benefits program.
Opponents contend
Critics, particularly from the PBM industry, might argue that these regulations could increase overall costs for the TRICARE program, potentially leading to higher premiums or reduced benefits elsewhere. They may contend that PBMs play a crucial role in negotiating lower drug prices and managing pharmacy networks efficiently, and that excessive regulation could disrupt these cost-saving mechanisms and increase administrative burdens without clear benefits.
The bill is short and relatively straightforward, allowing for a quick read and understanding of its core provisions.
Section 2(a)
Beneficiary Election for Non-Generic Maintenance Medications
This provision amends existing law to allow TRICARE beneficiaries, starting October 1, 2026, to choose any available means (e.g., retail pharmacy, mail order, military treatment facility pharmacy) to receive their non-generic prescription maintenance medications. This change removes a current restriction that limits how these specific types of medications can be obtained, aiming to provide greater flexibility and convenience for beneficiaries.
Supporters argue
Proponents argue that this provision enhances patient-centered care by giving TRICARE beneficiaries more control over their healthcare choices, ensuring they can use the pharmacy that best meets their needs, whether due to location, relationship with pharmacists, or other personal preferences.
Critics contend
Opponents might argue that expanding choice could lead to higher costs for the TRICARE program if retail pharmacies are more expensive than mail-order options, potentially negating some of the cost-saving measures PBMs are designed to provide.
Tradeoffs
The tension lies between maximizing beneficiary choice and potentially increasing program costs. While choice is generally beneficial for patients, it may come with a higher price tag if retail pharmacy dispensing is more expensive than centralized mail-order services.
Section 2(b)(1)
Pharmacy Benefit Manager Reimbursement Standards
This section mandates that contracts for the TRICARE pharmacy benefits program must ensure retail pharmacies are reimbursed at a rate that covers at least their actual cost of acquiring a drug from a wholesaler, or a proxy based on the National Average Drug Acquisition Cost (NADAC), plus a professional dispensing fee equivalent to what the state Medicaid program pays. This aims to prevent PBMs from reimbursing pharmacies below their cost.
Section 2(b)(2)
Prohibition on PBM Fees
This provision explicitly prohibits contractors administering the TRICARE pharmacy benefits program (i.e., PBMs) from imposing any fees on TRICARE retail pharmacies. This includes point-of-sale fees, retroactive fees (such as direct and indirect remuneration, or DIR fees), or any other indirect or hidden fees. The goal is to eliminate opaque and often unpredictable charges that reduce pharmacy reimbursement.
Section 2(b)(3)
Independent Audits of PBMs and Network Adequacy
This provision mandates that the Comptroller General of the United States (GAO) conduct annual audits of the TRICARE pharmacy benefits program. These audits will examine PBM data related to reimbursement rates and price concessions, as well as the adequacy of the TRICARE retail pharmacy network. The audit will assess beneficiary access, continuity of care, geographic accessibility (especially in rural areas), and whether beneficiary choices reflect personal preference. The results must be reported to Congress.
Allows beneficiaries to elect to receive non-generic prescription maintenance medications through 'any means described in paragraph (2)(E)'.
Section 2(a), amending 10 U.S.C. 1074g(a)(9)(D)
Why it matters:This is standard legislative drafting practice to avoid reprinting lengthy lists or definitions already present in statute, ensuring consistency and reducing bill length. It is not necessarily evasive.
Case for: This drafting method ensures legal precision and avoids redundancy, relying on existing statutory definitions for clarity.
Case against: For a casual reader, it requires additional research to fully understand the scope of beneficiary choice, making the bill less immediately accessible.
Estimated impact: The impact is to expand choice to all existing TRICARE pharmacy options, including retail pharmacies, mail order, and military treatment facility pharmacies, for non-generic maintenance medications.
Specifies that the proxy amount for reimbursement, in the absence of actual cost, shall be calculated at a rate not lower than the national average acquisition cost (NADAC) index published by the Administrator for the Centers for Medicare and Medicaid Services.
Section 2(b)(1)(A)(ii), amending 10 U.S.C. 1074g(i)(1)(A)(ii)
Why it matters:This is a technical detail necessary for precise calculation of reimbursement, relying on an established federal benchmark for drug pricing. It ensures a standardized and publicly available reference point.
Case for: Using NADAC provides a transparent, objective, and publicly available benchmark for drug acquisition costs, ensuring fair reimbursement without relying solely on potentially opaque 'actual cost' claims from pharmacies.
Case against: Some might argue that NADAC, while useful, may not always perfectly reflect the true acquisition costs for all pharmacies, especially smaller ones or those in specific geographic areas, potentially leading to continued under-reimbursement in some cases.
Estimated impact: Establishes a critical floor for drug reimbursement, potentially increasing payments to pharmacies for many common drugs.