I 112th CONGRESS 2d Session H. R. 4209 IN THE HOUSE OF REPRESENTATIVES March 19, 2012 Mr. McKinley (for himself, Mrs. Capps, Mr. Young of Florida, Mr. Cuellar, and Mr. Frank of Massachusetts) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend title XXVII of the Public Health Service Act to limit co-payment, coinsurance, or other cost-sharing requirements applicable to prescription drugs in a specialty drug tier to the dollar amount (or its equivalent) of such requirements applicable to prescription drugs in a non-preferred brand drug tier, and for other purposes.

1.

Short title

This Act may be cited as the Patients’ Access to Treatments Act of 2012.

2.

Co-payment, coinsurance, and other cost-sharing requirements applicable to prescription drugs in a specialty drug tier

(a)

In general

Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended by adding at the end the following:

2719B.

Co-payment, coinsurance, and other cost-sharing requirements applicable to prescription drugs in a specialty drug tier

(a)

Requirement

A group health plan, or a health insurance issuer offering group or individual health insurance, that provides coverage for prescription drugs and uses a formulary or other tiered cost-sharing structure shall not impose co-payment, coinsurance, or other cost-sharing requirements applicable to prescription drugs in a specialty drug tier that exceed the dollar amount (or its equivalent) of co-payment, coinsurance, or other cost-sharing requirements applicable to prescription drugs in a non-preferred brand drug tier (or prescription drugs in a brand drug tier if there is no non-preferred brand drug tier). (b)

Special rule

If a formulary used by a group health plan or a health insurance issuer offering group or individual health insurance contains more than one non-preferred brand drug tier, then the requirements of subsection (a) shall be applied with respect to the non-preferred brand drug tier for which beneficiary cost-sharing is lowest. (c)

Definitions

In this section: (1)The term prescription drug means— (A)a drug subject to section 503(b)(1) of the Federal Food, Drug, or Cosmetic Act; and (B)includes a drug described in subparagraph (A) that is a biological product (as defined in section 351(i) of this Act). (2)The term non-preferred brand drug tier means, with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage that uses a formulary or other tiered cost-sharing structure, a category of drugs— (A)within a tier in such formulary for which beneficiary cost-sharing is greater than tiers for generic drugs or preferred brand drugs in the plan’s formulary; (B)that are prescription drugs; and (C)that are not included within a specialty drug tier. (3)The term specialty drug tier means, with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage that uses a formulary or other tiered cost-sharing structure, a category of drugs— (A)within a tier in such formulary for which beneficiary cost-sharing is greater than tiers for generic drugs, preferred brand drugs, or non-preferred drugs in the plan’s formulary; and (B)that are prescription drugs.

. (b)

Effective date

Section 2719B of the Public Health Service Act, as added by subsection (a), applies to plan years beginning on or after the date of the enactment of this Act.