Ensuring cost sharing for a drug does not exceed the nationwide average of consumer purchase prices for such drug

(a)

PHSA

Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–111 et seq.) is amended by adding at the end the following new section:

2799A–12.

Limitation on cost sharing for drugs

(a)

In general

For plan years beginning on or after the date of the enactment of this section, a group health plan, and a health insurance issuer offering group or individual health insurance coverage, may not impose cost sharing (including deductibles, coinsurance, and copayments) with respect to a covered outpatient drug for which benefits are available under such plan or coverage dispensed by an in-network pharmacy in an amount that exceeds the nationwide average of consumer purchase prices for such drug for the 1-year period ending on the first day of such plan year (as determined using information from the survey described in section 1927(f)(1)(A)(i) of the Social Security Act). (b)

Clarification on application to pharmacy benefit managers

A group health plan, and a health insurance issuer offering group or individual health insurance coverage, shall ensure that any pharmacy benefit manager providing services under the plan or coverage complies with subsection (a) in the same manner as such subsection applies with respect to such plan or issuer. (c)

Definitions

In this section: (1)

Covered outpatient drug

The term covered outpatient drug has the meaning given such term in section 1927(k) of the Social Security Act. (2)

In-network pharmacy

The term in-network pharmacy means, with respect to a group health plan or group or individual health insurance coverage and a drug, a pharmacy with a contractual relationship in effect for dispensing such drug under such plan or coverage.

(b)

ERISA

(1)

In general

Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section:

727.

Limitation on cost sharing for drugs

(a)

In general

For plan years beginning on or after the date of the enactment of this section, a group health plan, and a health insurance issuer offering group coverage, may not impose cost sharing (including deductibles, coinsurance, and copayments) with respect to a covered outpatient drug for which benefits are available under such plan or coverage dispensed by an in-network pharmacy in an amount that exceeds the nationwide average of consumer purchase prices for such drug for the 1-year period ending on the first day of such plan year (as determined using information from the survey described in section 1927(f)(1)(A)(i) of the Social Security Act). (b)

Clarification on application to pharmacy benefit managers

A group health plan, and a health insurance issuer offering group health insurance coverage, shall ensure that any pharmacy benefit manager providing services under the plan or coverage complies with subsection (a) in the same manner as such subsection applies with respect to such plan or issuer. (c)

Definitions

In this section: (1)

Covered outpatient drug

The term covered outpatient drug has the meaning given such term in section 1927(k) of the Social Security Act. (2)

In-network pharmacy

The term in-network pharmacy means, with respect to a group health plan or group health insurance coverage and a drug, a pharmacy with a contractual relationship in effect for dispensing such drug under such plan or coverage.

(2)

Clerical amendment

The table of contents in section 1 of such Act is amended by inserting after the item relating to section 715 the following new item:

Sec. 727. Limitation on cost sharing for drugs.

(c)

IRC

(1)

In general

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:

9827.

Limitation on cost sharing for drugs

(a)

In general

For plan years beginning on or after the date of the enactment of this section, a group health plan may not impose cost sharing (including deductibles, coinsurance, and copayments) with respect to a covered outpatient drug for which benefits are available under such plan dispensed by an in-network pharmacy in an amount that exceeds the nationwide average of consumer purchase prices for such drug for the 1-year period ending on the first day of such plan year (as determined using information from the survey described in section 1927(f)(1)(A)(i) of the Social Security Act). (b)

Clarification on application to pharmacy benefit managers

A group health plan shall ensure that any pharmacy benefit manager providing services under the plan complies with subsection (a) in the same manner as such subsection applies with respect to such plan. (c)

Definitions

In this section: (1)

Covered outpatient drug

The term covered outpatient drug has the meaning given such term in section 1927(k) of the Social Security Act. (2)

In-network pharmacy

The term in-network pharmacy means, with respect to a group health plan and a drug, a pharmacy with a contractual relationship in effect for dispensing such drug under such plan.

(2)

Clerical amendment

The table of sections for such subchapter is amended by adding at the end the following new item:

Sec. 9827. Limitation on cost sharing for drugs.