The bill amends the Medicare program (Title XVIII) to add pharmacist services to the list of covered services. It defines pharmacist services as those performed by a pharmacist licensed by the state, which could be furnished directly or on behalf of a pharmacy provider, and treated as covered physician services when appropriate.
The services must be provided in settings located in health professional shortage areas, medically underserved areas, or medically underserved populations, and they must be within the pharmacist’s legally authorized scope of practice. The bill also sets the framework for reimbursement by tying pharmacist payments to the physician fee schedule, with a specified payment formula, and directs the development of pharmacist-specific billing codes.
The changes would apply to services furnished on or after January 1, 2027, and require the Secretary of Health and Human Services to develop pharmacist-specific codes under the physician fee schedule.
At a Glance
What It Does
Adds a new pharmacist services category (KK) to the Medicare coverage rule, allowing licensed pharmacists to furnish certain services and be reimbursed similarly to physician-provided services.
Who It Affects
Medicare beneficiaries in shortage areas, licensed pharmacists, and pharmacy providers delivering covered services in eligible settings.
Why It Matters
Expands access to pharmacist-led care in underserved areas and creates a reimbursement pathway that aligns pharmacist services with physician services under Medicare.
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What This Bill Actually Does
The proposal changes how Medicare treats pharmacist services. Under the bill, a pharmacist who is licensed by the state could provide certain services and have them covered as if a physician performed them, as long as the services are within the pharmacist’s legal scope of practice and occur in health professional shortage areas, medically underserved areas, or medically underserved populations.
The policy also introduces a reimbursement mechanism where payments to pharmacists would be 80% of the lesser of the actual charge or 85% of the physician fee schedule amount, mirroring physician payments for comparable services. In addition, the Secretary would create pharmacist-specific billing codes under the physician fee schedule, and the amendments would take effect for services furnished on or after January 1, 2027.
These provisions aim to reduce access gaps by leveraging pharmacist-provided care while maintaining a physician-like payment framework. CMS would be responsible for implementing the new codes and ensuring consistent application of the new coverage rules.
The bill thus formalizes pharmacist services within Medicare’s coverage and payment structure and signals an intent to expand the role of pharmacists in delivering care to underserved populations.
The Five Things You Need to Know
The bill adds new pharmacist services (KK) to Medicare coverage.
Pharmacists must be licensed and act within their state’s scope of practice.
Services must occur in health professional shortage areas, medically underserved areas, or underserved populations.
Payment for pharmacist services is set at 80% of the lesser of actual charge or 85% of the physician fee schedule.
CMS must develop pharmacist-specific codes under the physician fee schedule; effective date is January 1, 2027.
Section-by-Section Breakdown
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Coverage for pharmacist services
Section 2(a) adds a new subparagraph KK to 1861(s)(2) establishing that pharmacist services furnished by a licensed pharmacist, either personally or on behalf of a pharmacy, are eligible for Medicare coverage. Conditions for coverage include that the pharmacist is legally authorized to perform the service in their state and that the service would otherwise be covered if furnished by a physician or as an incidental physician service. Coverage is restricted to settings located in health professional shortage areas, medically underserved areas, or medically underserved populations, aligning pharmacist service delivery with access-improvement goals.
Payment for pharmacist services
Section 2(b) modifies payment by removing the earlier HH subparagraphs and adding a new provision for pharmacist services. Payments shall be equal to 80% of the lesser of the actual charge or 85% of the fee schedule amount that would apply if a physician provided the service. This creates a physician-like payment structure for pharmacist-provided services, contingent on compliance with the defined coverage criteria.
Effective date and pharmacist codes
Section 2(c) establishes an effective date of January 1, 2027 for the amendments in sections 2(a) and 2(b). It also requires the Secretary of Health and Human Services to develop pharmacist-specific billing codes under the physician fee schedule (section 1848), ensuring standardized reimbursement for pharmacist services across the Medicare program.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Medicare beneficiaries in health professional shortage areas who gain access to pharmacist-led care and services.
- Licensed pharmacists who can bill for eligible services and expand their clinical role within the Medicare program.
- Pharmacy providers delivering covered pharmacist services, potentially increasing revenue streams in underserved markets.
- Rural health clinics and Federally Qualified Health Centers that partner with pharmacists to address care gaps in underserved populations.
Who Bears the Cost
- Medicare program responsibilities and costs rise to cover the additional pharmacist services.
- Beneficiaries may incur standard Part B coinsurance (often 20%) for the new covered services.
- Pharmacy entities may incur startup costs to implement new billing processes and codes and to comply with state scope-of-practice requirements.
- Implementation costs for CMS and CMS contractors associated with developing pharmacist-specific codes and training providers on the new coverage rules.
Key Issues
The Core Tension
Balancing expanded access to pharmacist-delivered care with uniform standards, cost containment, and professional boundaries across states and payer systems.
The bill hinges on state-by-state licensure and scope-of-practice rules, creating potential variability in what constitutes covered pharmacist services. Although the payment formula aligns pharmacist reimbursement with physician-like rates, the shift could have cost implications for the Medicare program and for beneficiaries who pay coinsurance.
The success of implementation rests on CMS developing standardized pharmacist-specific codes and ensuring consistent interpretation across states and provider types. While the approach promises greater access in underserved areas, it also raises questions about oversight, quality measurement, and the administrative burden on pharmacies and providers.
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