To amend title XXVII of the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to ensure cost sharing for a drug does not exceed the nationwide average of consumer purchase prices for such drug.
Summary
HR10133, introduced by Rep. Scholten, would cap drug cost-sharing at the nationwide average consumer price, directly pressuring PBM revenue models at UnitedHealth, CVS Health, and Cigna. The bill is in early stage with no cosponsors, limiting near-term market impact. No convergence signals identified.
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Key Takeaways
- 1.HR10133 caps drug cost-sharing at average consumer price, directly targeting PBM spread pricing.
- 2.Bill is early stage with zero cosponsors and no committee action, indicating low near-term passage probability.
- 3.Primary losers are PBM-heavy insurers: UnitedHealth ($UNH), CVS Health ($CVS), Cigna ($CI).
Market Implications
The bill poses a structural risk to PBM margins if enacted, but at current stage it is a tail risk. Shares of , $CVS, and $CI may see negligible reaction. The real market data provided does not include stock prices, so no price movement analysis is possible. Long-term, if the bill gains momentum, PBM revenue models could be disrupted, but that is not the current scenario.
Full Analysis
On August 20, 2026, Rep. Hillary Scholten (D-MI-3) introduced HR10133, which amends the Public Health Service Act, ERISA, and the Internal Revenue Code to require that cost-sharing for a drug not exceed the nationwide average of consumer purchase prices. The bill was referred to three committees: Energy and Commerce, Ways and Means, and Education and Workforce. As of the report date, it has zero cosponsors and no additional legislative actions, placing it very early in the legislative process.
The bill’s mechanism directly targets the PBM/insurer practice of setting copays and coinsurance based on list prices, often far above the actual net price after rebates. By tying cost-sharing to the average consumer purchase price, the bill would force PBMs and insurers to reduce patient out-of-pocket costs to align with what consumers actually pay out-of-pocket at the pharmacy. This would compress the revenue PBMs earn from spread pricing (the difference between what they charge insurers and reimburse pharmacies) and administrative fees tied to rebate negotiations.
No convergence signals are present in the provided data. The bill is isolated and lacks bipartisan support or committee momentum. The sponsor is a junior House member, and the bill is not a companion to any Senate measure. Given the early stage and low political capital, the probability of passage in the 119th Congress is low (estimated <10%).
Structural winners: None directly; drug manufacturers may benefit indirectly if the bill reduces patient out-of-pocket burden, potentially increasing prescription volume, but the effect is secondary. Structural losers: PBMs (UnitedHealth's Optum Rx, CVS Caremark, Cigna's Express Scripts) are most exposed. The impact on insurers is more muted because they can adjust premiums, but PBMs face direct revenue compression.
Timeline: The bill must clear at least one of the three committees, then pass the House, then the Senate, and be signed by the President. Given the current 119th Congress timeline (adjourns January 2027), the window for passage is narrow. No further actions are expected in the near term.
Intelligence Surface
Cross-referenced against federal contracts, SEC insider filings & congressional trade disclosures
No confirming evidence found yet from contracts, insider trades, or congressional activity
What the bill does
Cost-sharing cap tied to nationwide average consumer purchase price
Who must act
PBMs including CVS Caremark
What happens
Caremark must adjust its formularies and rebate agreements to ensure member cost-sharing does not exceed the average consumer price, reducing rebate income and spread revenue
Stock impact
Caremark is CVS's PBM, managing ~$150B in drug spend; the cap pressures its revenue model by limiting the ability to set higher copays after rebates, a key profit source
What the bill does
Cost-sharing cap tied to nationwide average consumer purchase price
Who must act
PBMs including Express Scripts (Cigna)
What happens
Express Scripts must reduce member cost-sharing to match average consumer prices, compressing PBM margins from drug price negotiations
Stock impact
Express Scripts is Cigna's PBM, covering ~100M lives; the cap directly reduces the spread between list price and net price that PBMs capture, impacting Cigna's PBM segment profitability
Key Legislators
Connected Signals
Matched on shared policy language across AI analyses, with ticker & timing weight
Improving Seniors’ Timely Access to Care Act of 2025
To amend title XXVII of the Public Health Service Act and title XVIII of the Social Security Act to require health insurance issuers and MA organizations to make publicly available certain information with respect to coverage request rejection.
PBM Act
PBM Act
Fair Care Act of 2026
A bill to amend title 10, United States Code, to improve access to certain medications under the TRICARE program, and for other purposes.
To direct the Secretary of Labor to require group health plans include certain information on claim denials in annual reports, and for other purposes.
Protecting Seniors and Stopping Fraudsters Act
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