H.R. 460 — Introduced in House

I 113th CONGRESS 1st Session H. R. 460 IN THE HOUSE OF REPRESENTATIVES February 4, 2013 Mr. McKinley (for himself, Mrs. Capps, Mrs. Capito, Mr. Young of Florida, Mr. Moran, Mr. Wolf, Mr. Tonko, Mr. Runyan, Mr. Conyers, Ms. Bonamici, Mr. Cicilline, Mr. DeFazio, Mr. Michaud, Mr. Farr, Ms. Pingree of Maine, Mr. Rangel, and Mr. Crenshaw) 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 2013. 2. 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. 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 cost-sharing requirements applicable to prescription drugs in a specialty drug tier that exceed the dollar amount (or its equivalent) of 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 cost-sharing includes co-payment and coinsurance. (2) The term 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 cost-sharing structure, a category of drugs— (A) within such formulary or structure for which the total dollar amount of cost-sharing requirements for any drug does not vary by more than ten percent from the total dollar amount of cost-sharing requirements for any other drug; and (B) that are prescription drugs. (3) 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 drug tier in such formulary or structure for which beneficiary cost-sharing is greater than drug tiers for generic drugs or preferred brand drugs in the formulary or structure; (B) that are prescription drugs; and (C) that are not included within a specialty drug tier. (4) 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). (5) 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 drug tier in such formulary or structure for which beneficiary cost-sharing is greater than drug 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.