Assuring Pharmacy Access and Choice for Medicare Beneficiaries
Section 6223 · Sec. 6223 ·
What this chapter is about
This part says a drug plan must let in any pharmacy that meets its standard terms. From 2029 those terms must be reasonable and relevant by standards the health chief sets. A pharmacy can report a plan that breaks them, and the plan can be fined. Reports on lone pharmacies are required, and $188,000,000 is put behind the work.
The document says “shall”Who acts: prescription drug plan sponsorsHow: statuteSec. 6223 in the PDF
What the document says
“A PDP sponsor offering a prescription drug plan shall permit any pharmacy that meets the standard contract terms and conditions under such plan to participate as a network pharmacy of such plan.”
Subsection (a) of section 6223 replaces section 1860D-4(b)(1)(A) of the Social Security Act. A prescription drug plan sponsor must let any pharmacy that meets the plan's standard contract terms and conditions join as a network pharmacy.
What the document actually says
“A PDP sponsor offering a prescription drug plan shall permit any pharmacy that meets the standard contract terms and conditions under such plan to participate as a network pharmacy of such plan.”
That sentence, in plain words
A drug plan must let in any pharmacy that meets its standard terms. That pharmacy joins the plan's group.
What this is about
A plan pays more, or only, at pharmacies in its group. A pharmacy shut out loses those customers. This says the plan may not shut out one that meets its terms.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: prescription drug plan sponsors, Secretary of Health and Human ServicesHow: statuteSec. 6223 in the PDF
What the document says
“Notwithstanding any other provision of law, for plan years beginning on or after January 1, 2029, in accordance with clause (i), contract terms and conditions offered by such PDP sponsor shall be reasonable and relevant according to standards established by the Secretary under subclause (II).”
For plan years beginning on or after January 1, 2029, the terms and conditions a sponsor offers must be reasonable and relevant according to standards the Secretary establishes. The Secretary must set those standards no later than the first Monday in April of 2028.
What the document actually says
“Notwithstanding any other provision of law, for plan years beginning on or after January 1, 2029, in accordance with clause (i), contract terms and conditions offered by such PDP sponsor shall be reasonable and relevant according to standards established by the Secretary under subclause (II).”
That sentence, in plain words
For plan years that start on or after January 1, 2029, the terms a plan offers must be fair and on point. The health chief sets the test for that.
What this is about
A plan could set terms so hard that no small pharmacy could meet them. That would undo the rule above. This puts a limit on the terms.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6223 in the PDF
What the document says
“Not later than April 1, 2027, for purposes of establishing the standards under subclause (II), the Secretary shall issue a request for information to seek input on trends in prescription drug plan and network pharmacy contract terms and conditions, current prescription drug plan and network pharmacy contracting practices”
By April 1, 2027 the Secretary must issue a request for information to inform the standards. It must seek input on contract trends and practices, whether reimbursement and dispensing fees cover pharmacies' ingredient and operational costs, the use of pharmacy quality measures, plan restrictions on dispensing, auditing practices, points in current regulation or guidance needing clarity, factors bearing on whether terms are reasonable and relevant, and other issues the Secretary finds appropriate.
What the document actually says
“Not later than April 1, 2027, for purposes of establishing the standards under subclause (II), the Secretary shall issue a request for information to seek input on trends in prescription drug plan and network pharmacy contract terms and conditions, current prescription drug plan and network pharmacy contracting practices”
That sentence, in plain words
By April 1, 2027 the health chief must ask the public for input. The questions cover how plans and pharmacies write their deals now.
What this is about
The input shapes the fairness test. The list of questions is long. One of them is whether what a plan pays covers what a drug costs the pharmacy.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6223 in the PDF
What the document says
“With respect to plan years beginning on or after January 1, 2028, the Secretary shall publish reports, at least once every 2 years until 2034, and periodically thereafter, that provide information, to the extent feasible, on--”
Subsection (b) of section 6223 adds a new subsection (e) to section 1860D-42 of the Social Security Act. From plan year 2028, the Secretary must publish reports at least every two years until 2034, and periodically after that, covering trends in what plans pay essential retail pharmacies and what those pharmacies pay plans, their participation in networks, their number, cost sharing and dispensing volume compared with other network pharmacies nearby, and a comparison between the two kinds of plan.
What the document actually says
“With respect to plan years beginning on or after January 1, 2028, the Secretary shall publish reports, at least once every 2 years until 2034, and periodically thereafter, that provide information, to the extent feasible, on--”
That sentence, in plain words
From plan year 2028 the health chief must put out reports. One comes at least every two years until 2034. Each covers the things listed next.
What this is about
The reports track how lone pharmacies fare against the rest. Trends show up over years. Without the reports there is no record to look at.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
“``(i) a rural area in which there is no other retail pharmacy within 10 miles, as determined by the Secretary;
``(ii) a suburban area in which there is no other retail pharmacy within 2 miles, as determined by the Secretary; or
``(iii) an urban area in which there is no other retail pharmacy within 1 mile, as determined by the Secretary.”
The new subsection defines essential retail pharmacy as a retail pharmacy that is not an affiliate as defined in paragraph (4) and that stands alone within 10 miles in a rural area, 2 miles in a suburban area, or 1 mile in an urban area, as the Secretary determines. Affiliate and pharmacy benefit manager take their meaning from section 1860D-12(h)(7).
What the document actually says
“``(i) a rural area in which there is no other retail pharmacy within 10 miles, as determined by the Secretary;
``(ii) a suburban area in which there is no other retail pharmacy within 2 miles, as determined by the Secretary; or
``(iii) an urban area in which there is no other retail pharmacy within 1 mile, as determined by the Secretary.”
That sentence, in plain words
In the country, no other pharmacy within ten miles. In the suburbs, none within two miles. In a city, none within one mile.
What this is about
These are the pharmacies with no near rival. If one closes, its customers must travel. The pharmacy must also not be tied to a plan.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human Services, prescription drug plan sponsors, Medicare Advantage organizationsHow: statuteSec. 6223 in the PDF
What the document says
“For each plan year (beginning with plan year 2028), the Secretary shall publish, on a publicly available internet website of the Centers for Medicare & Medicaid Services, a list of retail pharmacies that meet the criteria described in subparagraphs (A) and (B) of paragraph (2) to be considered an essential retail pharmacy.”
For each plan year from 2028, the Secretary must publish a list of qualifying pharmacies on a public website. Sponsors and Medicare Advantage organizations must submit a list of retail pharmacies that are their affiliates, or affiliates of a pharmacy benefit manager acting for them. From plan year 2027 they must also report incentive payments and other fees paid to pharmacies where not otherwise reported. The Secretary may implement by program instruction, and chapter 35 of title 44 does not apply.
What the document actually says
“For each plan year (beginning with plan year 2028), the Secretary shall publish, on a publicly available internet website of the Centers for Medicare & Medicaid Services, a list of retail pharmacies that meet the criteria described in subparagraphs (A) and (B) of paragraph (2) to be considered an essential retail pharmacy.”
That sentence, in plain words
From plan year 2028 the health chief must publish a list. It names the retail pharmacies that meet the test above. Anyone can read it.
What this is about
The agency cannot build the list alone. Plans must say which pharmacies they own or are tied to. Those pharmacies do not count.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6223 in the PDF
What the document says
“Not later than January 1, 2029, the Secretary shall establish a process through which a pharmacy may submit to the Secretary an allegation of a violation by a PDP sponsor offering a prescription drug plan of the standards for reasonable and relevant contract terms and conditions”
Subsection (c) of section 6223 adds a new subparagraph (F) to section 1860D-4(b)(1) of the Social Security Act. By January 1, 2029 the Secretary must set up a process for a pharmacy to allege that a sponsor broke the reasonable and relevant standards, or the anti-retaliation rule. A pharmacy may file once per plan year per contract, with an extra filing allowed where the contract is later modified. The Secretary must supply a standardized template requiring a certification of accuracy, and may temporarily bar a pharmacy that files frivolous allegations on a routine basis.
What the document actually says
“Not later than January 1, 2029, the Secretary shall establish a process through which a pharmacy may submit to the Secretary an allegation of a violation by a PDP sponsor offering a prescription drug plan of the standards for reasonable and relevant contract terms and conditions”
That sentence, in plain words
By January 1, 2029 the health chief must set up a way for a pharmacy to report a plan. The report says the plan broke the fairness rule.
What this is about
A pharmacy may file once a year for each deal it has. If the deal changes, it may file again. A set form must be used.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall not”Who acts: prescription drug plan sponsorsHow: statuteSec. 6223 in the PDF
What the document says
“shall not prohibit or otherwise limit the ability of a pharmacy to submit such documents or materials to the Secretary for the purpose of submitting an allegation or providing evidence for such an allegation under this clause.”
A sponsor subject to an allegation must give the Secretary the documents or materials the Secretary specifies, including contract offers and related correspondence, and may not stop or limit a pharmacy from sending those documents to the Secretary. Allegations submitted are exempt from disclosure under section 552 of title 5, United States Code, and nothing in the clause limits a pharmacy's other legal remedies.
What the document actually says
“shall not prohibit or otherwise limit the ability of a pharmacy to submit such documents or materials to the Secretary for the purpose of submitting an allegation or providing evidence for such an allegation under this clause.”
That sentence, in plain words
A plan may not stop a pharmacy from sending papers to the health chief. That holds when the papers back up a report.
What this is about
The papers are often the deal itself and letters about it. A gag clause would make a report hard to prove. The reports are also kept from public release.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall not”Who acts: prescription drug plan sponsorsHow: statuteSec. 6223 in the PDF
What the document says
“``(aa) retaliate against a pharmacy for submitting any allegations under this clause; or
``(bb) coerce, intimidate, threaten, or interfere with the ability of a pharmacy to submit any such allegations.”
The new subparagraph bars a sponsor, consistent with applicable federal or state law, from retaliating against a pharmacy for filing an allegation, or from coercing, intimidating, threatening or interfering with its ability to file one.
What the document actually says
“``(aa) retaliate against a pharmacy for submitting any allegations under this clause; or
``(bb) coerce, intimidate, threaten, or interfere with the ability of a pharmacy to submit any such allegations.”
That sentence, in plain words
A plan may not hit back at a pharmacy for filing a report. A plan may not scare or block one that wants to file.
What this is about
A pharmacy depends on the plan for business. Fear of losing that would keep reports from ever being filed.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6223 in the PDF
What the document says
“The Secretary shall investigate, as determined appropriate by the Secretary, allegations submitted pursuant to clause (i).”
The new subparagraph requires the Secretary to investigate allegations as the Secretary finds appropriate. Where the Secretary finds a sponsor broke the reasonable and relevant standards or the anti-retaliation rule, the Secretary may use the authorities in sections 1857(g) and 1860D-12(b)(3)(E) to impose civil monetary penalties or other intermediate sanctions, and section 1128A applies to such a penalty other than its subsections (a) and (b). Section 6223 also adds a matching ground to the list in section 1857(g)(1).
What the document actually says
“The Secretary shall investigate, as determined appropriate by the Secretary, allegations submitted pursuant to clause (i).”
That sentence, in plain words
The health chief must look into the reports that come in. How far to look is left to the chief.
What this is about
A finding can lead to a money penalty. It can also lead to lesser steps. A report with no follow-up would mean nothing.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: pharmacy benefit managers, prescription drug plan sponsorsHow: statuteSec. 6223 in the PDF
What the document says
“each contract entered into with a PDP sponsor under this part with respect to a prescription drug plan offered by such sponsor shall provide that any pharmacy benefit manager acting on behalf of such sponsor has a written agreement with the PDP sponsor under which the pharmacy benefit manager agrees to reimburse the PDP sponsor for any amounts paid”
Subsection (d) of section 6223 adds a new paragraph (9) to section 1860D-12(b) of the Social Security Act. For plan years beginning on or after January 1, 2029, a contract with a sponsor must provide that a pharmacy benefit manager acting for the sponsor has a written agreement to reimburse the sponsor for penalties paid to the Secretary, where the violation related to a responsibility the sponsor delegated to the manager. The same rule is applied to MA-PD plans through section 1857(f)(3).
What the document actually says
“each contract entered into with a PDP sponsor under this part with respect to a prescription drug plan offered by such sponsor shall provide that any pharmacy benefit manager acting on behalf of such sponsor has a written agreement with the PDP sponsor under which the pharmacy benefit manager agrees to reimburse the PDP sponsor for any amounts paid”
That sentence, in plain words
The deal must say that the drug middleman signs a written promise. The promise is to pay the plan back for what the plan is fined.
What this is about
A plan often hands the pharmacy deals to a middleman. Then the plan gets fined for what the middleman did. This makes the middleman carry the cost.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6223 in the PDF
What the document says
“Not later than 2 years after the date of enactment of this subsection, and at least once every 2 years thereafter, the Secretary shall publish a report on enforcement and oversight actions and activities undertaken by the Secretary with respect to the requirements under section 1860D-4(b)(1).”
Subsection (e) of section 6223 adds a new subsection (f) to section 1860D-42 of the Social Security Act. The Secretary must publish a report on enforcement and oversight within two years of enactment and at least every two years after. The report may not disclose identifiable information about individuals or entities unless already public, or trade secrets.
What the document actually says
“Not later than 2 years after the date of enactment of this subsection, and at least once every 2 years thereafter, the Secretary shall publish a report on enforcement and oversight actions and activities undertaken by the Secretary with respect to the requirements under section 1860D-4(b)(1).”
That sentence, in plain words
Within two years the health chief must put out a report on this work. Another comes at least every two years after that.
What this is about
The report says what the agency did about the reports it got. It leaves out names and trade secrets. That keeps the record public without naming people.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Centers for Medicare & Medicaid ServicesHow: statuteSec. 6223 in the PDF
What the document says
“In addition to amounts otherwise available, there is appropriated to the Centers for Medicare & Medicaid Services Program Management Account, out of any money in the Treasury not otherwise appropriated, $188,000,000 for fiscal year 2026, to remain available until expended, to carry out this section.”
Subsection (f) of section 6223 appropriates $188,000,000 to the Centers for Medicare and Medicaid Services Program Management Account for fiscal year 2026, in addition to amounts otherwise available, to remain available until expended, to carry out the section.
What the document actually says
“In addition to amounts otherwise available, there is appropriated to the Centers for Medicare & Medicaid Services Program Management Account, out of any money in the Treasury not otherwise appropriated, $188,000,000 for fiscal year 2026, to remain available until expended, to carry out this section.”
That sentence, in plain words
The sum of $188,000,000 goes to one account for 2026. It may be held until it is spent. It pays for the work of this part.
What this is about
This is the largest sum in this title. The work here is heavy: new standards, a complaint system, and reports for years.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
Consolidated Appropriations Act, 2026, Public Law 119-75, sec. 6223, 140 Stat. 664 (2026). https://www.govinfo.gov/content/pkg/PLAW-119publ75/html/PLAW-119publ75.htm
This page
“Assuring Pharmacy Access and Choice for Medicare Beneficiaries,” Consolidated Appropriations Act, 2026, section 6223. Read the Mandate, https://readthemandate.org/consolidated-appropriations-act-2026/section-6223/ (retrieved August 26, 2026).
Cite the document when the claim is about what the document says. Cite this page when the indexing, the wording or the record of what has happened is what is being relied on.
What This Page Covers, and What It Leaves Out
The main things the section does: require any willing pharmacy participation, require reasonable and relevant contract terms from 2029 with standards due in 2028 and a request for information due in 2027, require reports on essential retail pharmacies and define that term, require lists and submissions, set up an allegation process with its safeguards, provide for investigation and penalties, make pharmacy benefit managers reimburse sponsors for penalties on delegated work, require a biennial report, and appropriate funding.
The topics the request for information must cover and the items the reports must contain, listed one by one. Both are recorded in summary.
The section amends the Social Security Act, which is not indexed here, so what the part D program otherwise requires is not recorded on this site.
