,i  #aaf? ,,congress  #a/ ,session  ,h4 
,r4 #bbgi  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,april #aj1 #bjai,mr4 
,ruiz 7= himself & ,mr4 ,w5/rup7        
introduc$ ! foll[+ bill2 :i* 0 ref]r$ to
 ! ,committee on ,education & ,labor  ,a
 ,,bill  ,to am5d ! ,employee ,retirem5t
 ,income ,security ,act ( #aigd to      
require a gr\p heal? plan 7or heal?     
insurance cov]age (f]$ 9 connection )   
su* a plan7 to provide an exceptions    
process = any m$ication /ep !rapy       
protocol1 & = o!r purposes4  #a4 ,%ort  
title ,?is ,act may be cit$ z ! ,safe   
,/ep ,act4  #b4 ,requir$ exceptions     
process = m$ication /ep !rapy protocols 
7a7 ,9 g5]al ,! ,employee ,retirem5t    
,income ,security ,act ( #aigd is am5d$ 
by ins]t+ aft] section #gae ( su* ,act  
7#bi ,u4,s4,c4 #aahe;d7 ! foll[+ new    
section3  #gaf4 ,requir$ exceptions     
process = m$ication /ep !rapy protocols 
7a7 ,9 g5]al ,9 ! case ( a gr\p heal?   
plan 7or heal? insurance cov]age (f]$ 9 
connection ) su* a plan7 t provides     

cov]age ( a prescription drug pursuant  
to a m$ication /ep !rapy protocol1 !    
plan or cov]age %all--  7#a7 implem5t a 
cle> process = a p>ticipant or b5efici>y
 7or ! prescrib+ heal? c>e provid]7 to  
reque/ an exception to su* m$ication /ep
 !rapy protocol2 &  7#b7 if su* a reque/
 demon/rates 7?r\gh support+            
docum5tation1 if necess>y7 t any ( !    
circum/ances li/$ 9 subsection 7b7      
exi/s1 au?orize cov]age = ! prescription
 drug )\t reg>d to su* m$ication /ep    
!rapy protocol4  7b7 ,exp$it$ approval  
,! circum/ances w>rant+ an exception to 
a m$ication /ep !rapy protocol1 pursuant
 to a reque/ "u subsection 7a71 are any 
( ! foll[+3  7#a7 ,! treatm5t o!rwise   
requir$ "u ! protocol1 or a drug or     
drugs 9 ! same ph>macological class or  
hav+ ! same me*anism ( action1 are      
contra9dicat$ or h be5 ineffective 9 !  
treatm5t ( ! disease or condition ( !   
p>ticipant or b5efici>y4  7#b7 ,!       
treatm5t o!rwise requir$ "u ! protocol  
is reasonably expect$ to be ineffective 

bas$ ^u--  7,a7 ! kn[n physical or m5tal
 *>act]i/ics ( ! p>ticipant or          
b5efici>y1 includ+ m$ical hi/ory2 &     
7,b7 ! kn[n *>act]i/ics ( su* treatm5t4 
7#c7 ,! treatm5t o!rwise requir$ "u !   
protocol w cause or is likely to cause  
an adv]se reaction or o!r physical h>m  
to ! p>ticipant or b5efici>y4  7#d7 ,!  
treatm5t o!rwise requir$ "u ! protocol  
is n 9 ! be/ int]e/ ( ! p>ticipant or   
b5efici>y1 bas$ on m$ical necessity1    
because ! p>ticipant or b5efici>y's use 
( su* treatm5t is expect$ to decrease ! 
p>ticipant or b5efici>y's ability--     
7,a7 to a*ieve or ma9ta9 reasonable &   
safe functional ability 9 p]=m+ daily   
activities or occupational              
responsibilities2 or  7,b7 to adh]e to !
 treatm5t plan z def9$ by ! prescrib+   
heal? c>e provid]4  7#e7 ,! p>ticipant  
or b5efici>y is /able = 8 or h] disease 
or condition on ! prescription drug or  
drugs select$ by ! prescrib+ heal? c>e  
provid]4  7c7 ,cle> process ,! process  
requir$ by subsection 7a77#a7-- 7#a7    

%all make in=mation reg>d+ su* process  
readily available on ! website ( ! gr\p 
heal? plan1 includ+--  7,a7 !           
requirem5ts = reque/+ an exception to a 
m$ication /ep !rapy protocol pursuant to
 ?is section2 &  7,b7 any necess>y =ms1 
support+ in=mation1 & contact in=mation2
 &  7#b7 may n require ! submission (   
any in=mation or support+ docum5tation  
beyond :at is /rictly necess>y to       
det]m9e :e!r any ( ! circum/ances li/$ 9
 subsection 7b7 exi/s4  7d7 ,tim+ =     
grant+ exception ,! process requir$ by  
subsection 7a77#a7 %all provide = !     
disposition ( reque/s receiv$ "u su*    
p>agraph 9 accordance ) ! foll[+3  7#a7 
,su* a reque/ %all be grant$ z quickly z
 ! disease or condition ( ! p>ticipant  
or b5efici>y requires1 b no lat] ?an #c 
days aft] ! day ( receipt ( ! reque/4   
7#b7 ,= circum/ances 9 :i* ! applicable 
m$ication /ep !rapy protocol may s]i\sly
 jeop>dize ! life1 heal?1 or ability to 
rega9 maximum function ( ! p>ticipant or
 b5efici>y1 su* a reque/ %all be        

grant$--  7,a7 on an exp$it$ basis2 &   
7,b7 no lat] ?an #bd h\rs aft] receipt (
 su* reque/4  7e7 ,m$ication /ep !rapy  
protocol ,9 ?is section1 ! t]m m$ication
 /ep !rapy protocol means a protocol or 
program t e/abli%es a specific sequ5ce 9
 :i* prescription drugs t-- 7#a7 are = a
 specifi$ disease or condition2 &  7#b7 
are m$ically necess>y = a p>ticul>      
pati5t1  are cov]$ "u a ph>macy or      
m$ical b5efit by a gr\p heal? plan or a 
heal? insurance issu] (f]+ gr\p or      
individual heal? insurance cov]age4  7f7
 ,cl>ification ,?is section %all apply )
 respect to any gr\p heal? plan 7or     
heal? insurance cov]age (f]$ 9          
connection ) su* a plan7 t provides     
cov]age ( a prescription drug pursuant  
to a policy t meets ! def9ition ( ! t]m 
m$ication /ep !rapy protocol 9          
subsection 7e71 reg>dless ( :e!r su*    
policy is describ$ by su* gr\p heal?    
plan 7or heal? insurance cov]age7 z a   
/ep !rapy protocol4  4  7b7 ,te*nical   
correction2 cl]ical *ange ,! table (    

cont5ts 9 section #a ( ! ,employee      
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #ajja et seq47 is  
am5d$ by ins]t+ aft] ! item relat+ to   
section #gad ! foll[+ new items3  ,sec4 
#gae4 ,additional m>ket re=ms4 ,sec4    
#gaf4 ,requir$ exceptions process =     
m$ication /ep !rapy protocols4  4  7c7  
,effective date  7#a7 ,9 g5]al ,!       
am5dm5t made by subsection 7a7 applies  
to plan ye>s beg9n+ no soon] ?an #f     
mon?s aft] ! date ( ! enactm5t ( ?is    
,act4  7#b7 ,regulations ,n lat] ?an !  
date t is #i mon?s aft] ! date ( !      
enactm5t ( ?is ,act1 ! ,secret>y (      
,labor %all issue f9al regulations1     
?r\gh notice & comm5t rulemak+1 to      
implem5t ! provisions ( section #gaf ( !
 ,employee ,retirem5t ,income ,security 
,act ( #aigd1 z add$ by subsection 7a74