I 

112TH CONGRESS 

2D SESSION H. R. 4209 

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. 

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 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Patients’ Access to 

3 Treatments Act of 2012’’. 

4 SEC. 2. CO-PAYMENT, COINSURANCE, AND OTHER COST5 SHARING REQUIREMENTS APPLICABLE TO 

6 PRESCRIPTION DRUGS IN A SPECIALTY DRUG 

7 TIER. 

8 (a) IN GENERAL.—Subpart II of part A of title 

9 XXVII of the Public Health Service Act (42 U.S.C. 300gg 

10 et seq.) is amended by adding at the end the following: 

11 ‘‘SEC. 2719B. CO-PAYMENT, COINSURANCE, AND OTHER 

12 COST-SHARING REQUIREMENTS APPLICABLE 

13 TO PRESCRIPTION DRUGS IN A SPECIALTY 

14 DRUG TIER. 

15 ‘‘(a) REQUIREMENT.—A group health plan, or a 

16 health insurance issuer offering group or individual health 

17 insurance, that provides coverage for prescription drugs 

18 and uses a formulary or other tiered cost-sharing struc19 ture shall not impose co-payment, coinsurance, or other 

20 cost-sharing requirements applicable to prescription drugs 

21 in a specialty drug tier that exceed the dollar amount (or 

22 its equivalent) of co-payment, coinsurance, or other cost23 sharing requirements applicable to prescription drugs in 

24 a non-preferred brand drug tier (or prescription drugs in 

25 a brand drug tier if there is no non-preferred brand drug 

26 tier). 


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1 ‘‘(b) SPECIAL RULE.—If a formulary used by a group 

2 health plan or a health insurance issuer offering group or 

3 individual health insurance contains more than one non4 preferred brand drug tier, then the requirements of sub5 section (a) shall be applied with respect to the non-pre6 ferred brand drug tier for which beneficiary cost-sharing 

7 is lowest. 

8 ‘‘(c) DEFINITIONS.—In this section: 

9 ‘‘(1) The term ‘prescription drug’ means— 

10 ‘‘(A) a drug subject to section 503(b)(1) of 

11 the Federal Food, Drug, or Cosmetic Act; and 

12 ‘‘(B) includes a drug described in subpara13 graph (A) that is a biological product (as de14 fined in section 351(i) of this Act). 

15 ‘‘(2) The term ‘non-preferred brand drug tier’ 

16 means, with respect to a group health plan or health 

17 insurance issuer offering group or individual health 

18 insurance coverage that uses a formulary or other 

19 tiered cost-sharing structure, a category of drugs— 

20 ‘‘(A) within a tier in such formulary for 

21 which beneficiary cost-sharing is greater than 

22 tiers for generic drugs or preferred brand drugs 

23 in the plan’s formulary; 

24 ‘‘(B) that are prescription drugs; and 


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1 ‘‘(C) that are not included within a spe2 cialty drug tier. 

3 ‘‘(3) The term ‘specialty drug tier’ means, with 

4 respect to a group health plan or health insurance 

5 issuer offering group or individual health insurance 

6 coverage that uses a formulary or other tiered cost7 sharing structure, a category of drugs— 

8 ‘‘(A) within a tier in such formulary for 

9 which beneficiary cost-sharing is greater than 

10 tiers for generic drugs, preferred brand drugs, 

11 or non-preferred drugs in the plan’s formulary; 

12 and 

13 ‘‘(B) that are prescription drugs.’’. 

14 (b) EFFECTIVE DATE.—Section 2719B of the Public 

15 Health Service Act, as added by subsection (a), applies 

16 to plan years beginning on or after the date of the enact17 ment of this Act. 

Æ 


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