I 112th CONGRESS 1st Session H. R. 2746 IN THE HOUSE OF REPRESENTATIVES August 1, 2011 Mr. Higgins introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend the Employee Retirement Income Security Act of 1974, the Public Health Service Act, and the Internal Revenue Code of 1986 to require group and individual health insurance coverage and group health plans to provide for coverage of oral anticancer drugs on terms no less favorable than the coverage provided for intravenously administered anticancer medications.

1.

Short title

This Act may be cited as the Cancer Drug Coverage Parity Act of 2011.

2.

Parity in coverage for oral anticancer drugs

(a)

Employee Retirement Income Security Act of 1974 amendments

(1)Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:

716.

Parity in coverage for oral anticancer drugs

(a)

In general

Subject to subsection (b), a group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides benefits with respect to intravenously administered or injected anticancer medications shall provide for no less favorable coverage for prescribed, orally administered anticancer medication that is used to kill or slow the growth of cancerous cells and that has been approved by the Food and Drug Administration. (b)

Limitation

Subsection (a) shall only apply to anticancer medication that is prescribed based on a finding by the treating physician that the medication— (1)is medically necessary for the purpose of killing or slowing the growth of cancerous cells in a manner that is in accordance with nationally accepted standards of medical practice; (2)is clinically appropriate in terms of type, frequency, extent site, and duration; and (3)is not primarily for the convenience of the patient, physician, or other health care provider. (c)

Application of cost-Sharing and restrictions

(1)

In general

The coverage of anticancer medication under subsection (a) may be subject to annual deductibles and coinsurance or copayments so long as such deductibles, coinsurance, and copayments do not exceed the deductibles, coinsurance, and copayments that are applicable to intravenously administered or injected anticancer medications under the plan or coverage for the same purpose. (2)

Restriction

A group health plan or health insurance issuer may not, in order to comply with the requirement of subsection (a)— (A)impose an increase in out-of-pocket costs with respect to anticancer medications; or (B)reclassify benefits with respect to anticancer medications. (d)

Application of notice, prohibitions, Etc

The provisions of subsections (b), (c), (d), and (e)(2) of section 713 shall apply with respect to the coverage required by subsection (a) in the same manner as they apply with respect to the coverage required under such section, except that January 1, 2012, shall be substituted for the date referred to in subsection (b)(3) of such section. (e)

Construction

Nothing in this section shall be construed— (1)to require the use of orally administered anticancer medications as a replacement for other anticancer medications; or (2)to prohibit a group health plan or health insurance issuer from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for any chemotherapy.

. (2)Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking section 711 and inserting sections 711 and 716. (3)Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking section 711 and inserting sections 711 and 716. (4)The table of contents in section 1 of such Act is amended by inserting after the item relating to section 714 the following new items: Sec. 715. Additional market reforms. Sec. 716. Parity in coverage for oral anticancer drugs. . (b)

Public health service act amendments

(1)Title XXVII of the Public Health Service Act is amended by inserting after section 2728 (42 U.S.C. 300gg–28), as redesignated by section 1001(2) of the Patient Protection and Affordable Care Act (Public Law 111–148), the following new section:

2729.

Parity in coverage for oral anticancer drugs

(a)

In general

Subject to subsection (b), a group health plan, and a health insurance issuer offering group or individual health insurance coverage, that provides benefits with respect to intravenously administered or injected anticancer medications shall provide for no less favorable coverage for prescribed, orally administered anticancer medication that is used to kill or slow the growth of cancerous cells and that has been approved by the Food and Drug Administration. (b)

Limitation

Subsection (a) shall only apply to anticancer medication that is prescribed based on a finding by the treating physician that the medication— (1)is medically necessary for the purpose of killing or slowing the growth of cancerous cells in a manner that is in accordance with nationally accepted standards of medical practice; (2)is clinically appropriate in terms of type, frequency, extent site, and duration; and (3)is not primarily for the convenience of the patient, physician, or other health care provider. (c)

Application of cost-Sharing and restrictions

(1)

In general

The coverage of anticancer medication under subsection (a) may be subject to annual deductibles and coinsurance or copayments so long as such deductibles, coinsurance, and copayments do not exceed the deductibles, coinsurance, and copayments that are applicable to intravenously administered or injected anticancer medications under the plan or coverage for the same purpose. (2)

Restriction

A group health plan or health insurance issuer may not, in order to comply with the requirement of subsection (a)— (A)impose an increase in out-of-pocket costs with respect to anticancer medications; or (B)reclassify benefits with respect to anticancer medications. (d)

Application of notice, prohibitions, Etc

The provisions of subsections (b), (c), (d), and (e)(2) of section 713 of the Employee Retirement and Income Security Act of 1974 shall apply with respect to the coverage required by subsection (a) in the same manner as they apply with respect to the coverage required under such section, except that January 1, 2012, shall be substituted for the date referred to in subsection (b)(3) of such section. (e)

Construction

Nothing in this section shall be construed— (1)to require the use of orally administered anticancer medications as a replacement for other anticancer medications; or (2)to prohibit a group health plan or health insurance issuer from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for any chemotherapy.

. (2)Section 2724(c) of such Act (42 U.S.C. 300gg–23(c)), as redesignated by section 1001(4) and subsection (c)(14) of the section 1563 (relating to conforming amendments) of Public Law 111–148, is amended by striking section 2704 and inserting sections 2725 and 2729. (3)Section 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)) is amended by striking section 2751 and inserting sections 2751 and 2729. (4)For purposes of applying section 2729 of the Public Health Service Act, as inserted by paragraph (1), to individual health insurance coverage before 2014, the provisions of such section shall be treated as also included under part B of title XXVII of the Public Health Service Act. (c)

Internal revenue code amendments

(1)

In general

Subchapter B of chapter 100 of the Internal Revenue Code of 1986, as amended by subsection (f) of the section 1563 (relating to conforming amendments) of Public Law 111–148, is amended by adding at the end the following new section:

9816.

Parity in coverage for oral anticancer drugs

(a)

In general

Subject to subsection (b), a group health plan that provides benefits with respect to intravenously administered or injected anticancer medications shall provide for no less favorable coverage for prescribed, orally administered anticancer medication that is used to kill or slow the growth of cancerous cells and that has been approved by the Food and Drug Administration. (b)

Limitation

Subsection (a) shall only apply to anticancer medication that is prescribed based on a finding by the treating physician that the medication— (1)is medically necessary for the purpose of killing or slowing the growth of cancerous cells in a manner that is in accordance with nationally accepted standards of medical practice; (2)is clinically appropriate in terms of type, frequency, extent site, and duration; and (3)is not primarily for the convenience of the patient, physician, or other health care provider. (c)

Application of cost-Sharing and restrictions

(1)

In general

The coverage of anticancer medication under subsection (a) may be subject to annual deductibles and coinsurance or copayments so long as such deductibles, coinsurance, and copayments do not exceed the deductibles, coinsurance, and copayments that are applicable to intravenously administered or injected anticancer medications under the plan for the same purpose. (2)

Restriction

A group health plan may not, in order to comply with the requirement of subsection (a)— (A)impose an increase in out-of-pocket costs with respect to anticancer medications; or (B)reclassify benefits with respect to anticancer medications. (d)

Application of notice, prohibitions, Etc

The provisions of subsections (b), (c), (d), and (e)(2) of section 713 of the Employee Retirement and Income Security Act of 1974 shall apply with respect to the coverage required by subsection (a) in the same manner as they apply with respect to the coverage required under such section, except that January 1, 2012, shall be substituted for the date referred to in subsection (b)(3) of such section. (e)

Construction

Nothing in this section shall be construed— (1)to require the use of orally administered anticancer medications as a replacement for other anticancer medications; or (2)to prohibit a group health plan or health insurance issuer from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for any chemotherapy.

. (2)

Clerical amendment

The table of sections for such subchapter is amended by adding at the end the following new items: Sec. 9815. Additional market reforms. Sec. 9816. Parity in coverage for oral anticancer drugs. . (d)

Clarifying amendment regarding application to grandfathered plans

Section 1251(a)(4)(A) of the Patient Protection and Affordable Care Act (Public Law 111–148; 42 U.S.C. 18011(a)(4)(A)), as added by section 2301(a) of Public Law 111–152, is amended by adding at the end the following new clause: (v)Section 2729 (relating to standards relating to benefits for minor child’s congenital or developmental deformity or disorder), as added by section 2(b) of the Cancer Drug Coverage Parity Act of 2011. . (e)

Effective date

The amendments made by this section shall apply with respect to group health plans for plan years beginning on or after January 1, 2012, and with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date. (f)

Study

Not later than 2 years after the date of the enactment of this Act— (1)the Medicare Payment Advisory Commission shall complete a study that assesses how closing the Medicare part D donut hole under the amendments made by section 3301 of the Patient Protection and Affordable Care Act (Public Law 111–148), as amended by section 1101 of the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152), affects Medicare coverage for orally administered anticancer medications, with a particular focus on cost and accessibility; and (2)submit a report to Congress on the results of such study.