,,ii  #aahth ,,congress  #ast ,session  
,s4 #adf  ,,in ,,the ,,senate ,,of ,,the
 ,,united ,,states  ,january #cj1       
#bjbc,mr4 ,hawley introduced the        
following bill2 which was read twice and
 referred to the ,committee on ,health1 
,education1 ,labor1 and ,pensions  ,a   
,,bill  ,to reduce the price of insulin 
for patients4  #a4 ,short title ,this   
,act may be cited as the ,cap ,insulin  
,prices ,act4  #b4 ,reduction in        
cost-sharing for covered insulin        
products under ,medicare part ,d        
,section #ahfj;,d-#b7;b77#i77;,d7 of the
 ,social ,security ,act 7#db ,u4,s4,c4  
#aciew-#ajb7;b77#i77;,d77 is amended--  
7#a7 by redesignating clause 7ii7 as    
clause 7iii72  7#b7 in clause 7i7-- 7,a7
 by striking plan years #bjbc1 #bjbd1   
and #bjbe and inserting plan year #bjbc2
 and  7,b7 by striking and after the    
semicolon at the end2  7#c7 by inserting
 after clause 7i7 the following new     
clause3  7ii7 during plan years #bjbd   
and #bjbe1 #be2 and  2 and  7#d7 in     

clause 7iii77,i71 as redesignated by    
paragraph 7#a7 of this section1 by      
striking #ce and inserting #be4  #c4    
,requirements with respect to           
cost-sharing for insulin products  7a7  
,in general ,part ,d of title ,,xxvii of
 the ,public ,health ,service ,act 7#db 
,u4,s4,c4 #cjj;gg-#aaa et seq47 is      
amended by adding at the end the        
following3  #bgii;,a-#aa4 ,requirements 
with respect to cost-sharing for certain
 insulin products  7a7 ,in general ,for 
plan years beginning on or after        
,january #a1 #bjbd1 a group health plan 
or health insurance issuer offering     
group or individual health insurance    
coverage shall provide coverage of      
selected insulin products1 and with     
respect to such products1 shall not--   
7#a7 apply any deductible2  7#b7 impose 
any cost-sharing requirement in excess  
of the lesser of1 per #cj-;day supply-- 
7,a7 #be2 or  7,b7 the amount equal to  
#be percent of the negotiated price of  
the selected insulin product net of all 

price concessions received by or on     
behalf of the plan or coverage1         
including price concessions received by 
or on behalf of third-party entities    
providing services to the plan or       
coverage1 such as pharmacy benefit      
management services2 or  7#c7 impose any
 utilization management practices such  
as prior authorization1 step therapy    
protocols1 or other similar conditions  
on such products1 except as clinically  
justified and as specified by the       
,secretary4  7b7 ,definitions ,in this  
section3 7#a7 ,selected insulin products
 ,the term selected insulin products    
means at least one of each dosage form  
7such as vial1 pump1 or inhaler dosage  
forms7 of each different type 7such as  
rapid-acting1 short-acting1             
intermediate-acting1 long-acting1 ultra 
long-acting1 and premixed7 of insulin   
7as defined below71 when available1 as  
selected by the group health plan or    
health insurance issuer4  7#b7 ,insulin 
defined ,the term insulin means insulin 

that is licensed under subsection 7a7 or
 7k7 of section #cea and continues to be
 marketed under such section4  7c7      
,out-of-,network providers ,nothing in  
this section requires a plan or issuer  
that has a network of providers to      
provide benefits for selected insulin   
products described in this section that 
are delivered by an out-of-network      
provider1 or precludes a plan or issuer 
that has a network of providers from    
imposing higher cost-sharing than the   
levels specified in subsection 7a7 for  
selected insulin products described in  
this section that are delivered by an   
out-of-network provider4  7d7 ,rule of  
construction ,subsection 7a7 shall not  
be construed to require coverage of1 or 
prevent a group health plan or health   
insurance coverage from imposing        
cost-sharing other than the levels      
specified in subsection 7a7 on1 insulin 
products that are not selected insulin  
products1 to the extent that such       
coverage is not otherwise required and  

such cost-sharing is otherwise permitted
 under ,federal and applicable ,state   
law4  7e7 ,application of cost-,sharing 
towards deductibles and out-of-,pocket  
maximums ,any cost-sharing payments made
 pursuant to subsection 7a77#b7 shall be
 counted toward any deductible or       
out-of-pocket maximum that applies under
 the plan or coverage4  4  7b7 ,no      
effect on other cost-,sharing ,section  
#acjb7;d77#b7 of the ,patient           
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjbb7;d77#b77 is       
amended by adding at the end the        
following new subparagraph3  7,d7       
,special rule relating to insulin       
coverage ,for plan years beginning on or
 after ,january #a1 #bjbd1 the exemption
 of coverage of selected insulin        
products 7as defined in section         
#bgii;,a-#aa7;b7 of the ,public ,health 
,service ,act7 from the application of  
any deductible pursuant to section      
#bgii;,a-#aa7;a77#a7 of such ,act1      
section #gbf7;a77#a7 of the ,employee   

,retirement ,income ,security ,act of   
#aigd1 or section #ihbf7;a77#a7 of the  
,internal ,revenue ,code of #aihf shall 
not be considered when determining the  
actuarial value of a qualified health   
plan under this subsection4  4  7c7     
,coverage of certain insulin products   
under catastrophic plans ,section       
#acjb7;e7 of the ,patient ,protection   
and ,affordable ,care ,act 7#db         
,u4,s4,c4 #ahjbb7;e77 is amended by     
adding at the end the following3  7#d7  
,coverage of certain insulin products   
7,a7 ,in general ,notwithstanding       
paragraph 7#a77;,b77i71 a health plan   
described in paragraph 7#a7 shall       
provide coverage of selected insulin    
products1 in accordance with section    
#bgii;,a-#aa of the ,public ,health     
,service ,act1 for a plan year before an
 enrolled individual has incurred       
cost-sharing expenses in an amount equal
 to the annual limitation in effect     
under subsection 7c77#a7 for the plan   
year4  7,b7 ,terminology ,for purposes  

of subparagraph 7,a7-- 7i7 the term     
selected insulin products has the       
meaning given such term in section      
#bgii;,a-#aa7;b7 of the ,public ,health 
,service ,act2 and  7ii7 the            
requirements of section #bgii;,a-#aa of 
such ,act shall be applied by deeming   
each reference in such section to       
individual health insurance coverage to 
be a reference to a plan described in   
paragraph 7#a74  4  7d7 ,,erisa  7#a7   
,in general ,subpart ,b of part #g of   
subtitle ,b of title ,i of the ,employee
 ,retirement ,income ,security ,act of  
#aigd 7#bi ,u4,s4,c4 #aahe et seq47 is  
amended by adding at the end the        
following3  #gbf4 ,requirements with    
respect to cost-sharing for certain     
insulin products  7a7 ,in general ,for  
plan years beginning on or after        
,january #a1 #bjbd1 a group health plan 
or health insurance issuer offering     
group health insurance coverage shall   
provide coverage of selected insulin    
products1 and with respect to such      

products1 shall not-- 7#a7 apply any    
deductible2  7#b7 impose any            
cost-sharing requirement in excess of   
the lesser of1 per #cj-;day supply--    
7,a7 #be2 or  7,b7 the amount equal to  
#be percent of the negotiated price of  
the selected insulin product net of all 
price concessions received by or on     
behalf of the plan or coverage1         
including price concessions received by 
or on behalf of third-party entities    
providing services to the plan or       
coverage1 such as pharmacy benefit      
management services2 or  7#c7 impose any
 utilization management practices such  
as prior authorization1 step therapy    
protocols1 or other similar conditions  
on such products1 except as clinically  
justified and as specified by the       
,secretary4  7b7 ,definitions ,in this  
section3 7#a7 ,selected insulin products
 ,the term selected insulin products    
means at least one of each dosage form  
7such as vial1 pump1 or inhaler dosage  
forms7 of each different type 7such as  

rapid-acting1 short-acting1             
intermediate-acting1 long-acting1 ultra 
long-acting1 and premixed7 of insulin   
7as defined below71 when available1 as  
selected by the group health plan or    
health insurance issuer4  7#b7 ,insulin 
defined ,the term insulin means insulin 
that is licensed under subsection 7a7 or
 7k7 of section #cea of the ,public     
,health ,service ,act 7#db ,u4,s4,c4    
#bfb7 and continues to be marketed under
 such section4  7c7 ,out-of-,network    
providers ,nothing in this section      
requires a plan or issuer that has a    
network of providers to provide benefits
 for selected insulin products described
 in this section that are delivered by  
an out-of-network provider1 or precludes
 a plan or issuer that has a network of 
providers from imposing higher          
cost-sharing than the levels specified  
in subsection 7a7 for selected insulin  
products described in this section that 
are delivered by an out-of-network      
provider4  7d7 ,rule of construction    

,subsection 7a7 shall not be construed  
to require coverage of1 or prevent a    
group health plan or health insurance   
coverage from imposing cost-sharing     
other than the levels specified in      
subsection 7a7 on1 insulin products that
 are not selected insulin products1 to  
the extent that such coverage is not    
otherwise required and such cost-sharing
 is otherwise permitted under ,federal  
and applicable ,state law4  7e7         
,application of cost-,sharing towards   
deductibles and out-of-,pocket maximums 
,any cost-sharing payments made pursuant
 to subsection 7a77#b7 shall be counted 
toward any deductible or out-of-pocket  
maximum that applies under the plan or  
coverage4  4  7#b7 ,clerical amendment  
,the table of contents in section #a of 
the ,employee ,retirement ,income       
,security ,act of #aigd 7#bi ,u4,s4,c4  
#ajja et seq47 is amended by inserting  
after the item relating to section #gbe 
the following3  ,sec4 #gbf ,requirements
 with respect to cost-sharing for       

certain insulin products4  4  7e7       
,internal ,revenue ,code  7#a7 ,in      
general ,subchapter ,b of chapter #ajj  
of the ,internal ,revenue ,code of #aihf
 is amended by adding at the end the    
following new section3  #ihbf4          
,requirements with respect to           
cost-sharing for certain insulin        
products  7a7 ,in general ,for plan     
years beginning on or after ,january #a1
 #bjbd1 a group health plan shall       
provide coverage of selected insulin    
products1 and with respect to such      
products1 shall not-- 7#a7 apply any    
deductible2  7#b7 impose any            
cost-sharing requirement in excess of   
the lesser of1 per #cj-;day supply--    
7,a7 #be2 or  7,b7 the amount equal to  
#be percent of the negotiated price of  
the selected insulin product net of all 
price concessions received by or on     
behalf of the plan1 including price     
concessions received by or on behalf of 
third-party entities providing services 
to the plan1 such as pharmacy benefit   

management services2 or  7#c7 impose any
 utilization management practices such  
as prior authorization1 step therapy    
protocols1 or other similar conditions  
on such products1 except as clinically  
justified and as specified by the       
,secretary4  7b7 ,definitions ,in this  
section3 7#a7 ,selected insulin products
 ,the term selected insulin products    
means at least one of each dosage form  
7such as vial1 pump1 or inhaler dosage  
forms7 of each different type 7such as  
rapid-acting1 short-acting1             
intermediate-acting1 long-acting1 ultra 
long-acting1 and premixed7 of insulin   
7as defined below71 when available1 as  
selected by the group health plan4  7#b7
 ,insulin defined ,the term insulin     
means insulin that is licensed under    
subsection 7a7 or 7k7 of section #cea of
 the ,public ,health ,service ,act 7#db 
,u4,s4,c4 #bfb7 and continues to be     
marketed under such section4  7c7       
,out-of-,network providers ,nothing in  
this section requires a plan that has a 

network of providers to provide benefits
 for selected insulin products described
 in this section that are delivered by  
an out-of-network provider1 or precludes
 a plan that has a network of providers 
from imposing higher cost-sharing than  
the levels specified in subsection 7a7  
for selected insulin products described 
in this section that are delivered by an
 out-of-network provider4  7d7 ,rule of 
construction ,subsection 7a7 shall not  
be construed to require coverage of1 or 
prevent a group health plan from        
imposing cost-sharing other than the    
levels specified in subsection 7a7 on1  
insulin products that are not selected  
insulin products1 to the extent that    
such coverage is not otherwise required 
and such cost-sharing is otherwise      
permitted under ,federal and applicable 
,state law4  7e7 ,application of        
cost-,sharing towards deductibles and   
out-of-,pocket maximums ,any            
cost-sharing payments made pursuant to  
subsection 7a77#b7 shall be counted     

toward any deductible or out-of-pocket  
maximum that applies under the plan4  4 
7#b7 ,clerical amendment ,the table of  
sections for subchapter ,b of chapter   
#ajj of such ,code is amended by adding 
at the end the following new item3      
,sec4 #ihbf ,requirements with respect  
to cost-sharing for certain insulin     
products4  4  7f7 ,implementation ,the  
,secretary of ,health and ,human        
,services1 the ,secretary of ,labor1 and
 the ,secretary of the ,treasury shall  
implement the provisions of this        
section1 including the amendments made  
by this section1 through subregulatory  
guidance or program instruction4