II 

111TH CONGRESS 

1ST SESSION S. 1630 

To amend title XVIII of the Social Security Act to improve prescription 

drug coverage under Medicare part D and to amend the Public Health 

Service Act, the Employee Retirement Income Security Act of 1974, 

and the Internal Revenue Code of 1986, to improve prescription drug 

coverage under private health insurance, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

AUGUST 6, 2009 

Mr. ROCKEFELLER (for himself and Mr. FRANKEN) introduced the following 

bill; which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to improve 

prescription drug coverage under Medicare part D and 

to amend the Public Health Service Act, the Employee 

Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986, to improve prescription drug 

coverage under private health insurance, 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, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Affordable Access to 

5 Prescription Medications Act of 2009’’. 


jbell on DSKDVH8Z91PROD with BILLS
2 

•S 1630 IS

1 SEC. 2. MEDICARE PART D PRESCRIPTION DRUG PLANS. 

2 (a) IN GENERAL.—Section 1860D–2(b)(4) of the So3 cial Security Act (42 U.S.C. 1395w–102(b)(4)) is amend4 ed by adding at the end the following new subparagraph: 

5 ‘‘(E) ADDITIONAL PROTECTIONS.— 

6 ‘‘(i) IN GENERAL.—Notwithstanding 

7 any other provision of this part, effective 

8 for plan years beginning on or after Janu9 ary 1, 2011, a PDP sponsor of a prescrip10 tion drug plan and an MA organization of11 fering an MA–PD plan shall, with respect 

12 to any co-payment or coinsurance require13 ments applicable to covered part D drugs 

14 under the plan, ensure that— 

15 ‘‘(I) such required co-payment or 

16 coinsurance does not exceed the base 

17 cost of the covered part D drug (as 

18 determined by the Secretary); 

19 ‘‘(II) such required co-payment 

20 or coinsurance does not exceed $200 

21 per month for any single covered part 

22 D drug (30-day supply); and 

23 ‘‘(III) such required co-payment 

24 or coinsurance does not exceed, in the 

25 aggregate for all covered part D 

26 drugs, $500 per month. 


jbell on DSKDVH8Z91PROD with BILLS
3 

•S 1630 IS

1 ‘‘(ii) ADJUSTMENTS.—The amounts 

2 described in clauses (II) and (III) of clause 

3 (i) shall be annually adjusted to reflect the 

4 average of the percentage increase or de5 crease in the Consumer Price Index for all 

6 urban consumers (U.S. city average) and 

7 the percentage increase or decrease in the 

8 medical care component of such Consumer 

9 Price Index during the calendar year pre10 ceding the year for which the adjustment 

11 is being made.’’. 

12 (b) EXPANSION OF EXCEPTIONS PROCESS.—Effec13 tive for plan years beginning on or after January 1, 2011, 

14 the Secretary shall expand the formulary tier exception re15 quest process under sections 423.560 through 423.636 of 

16 title 42, Code of Federal Regulations (as in effect on the 

17 date of enactment of this Act), to allow individuals en18 rolled in a prescription drug plan under part D of title 

19 XVIII of the Social Security Act or an MA–PD plan under 

20 part C of such title to request an exception for a specialty 

21 prescription drug to a plan’s designation of a covered part 

22 D drug (as defined in section 1860D–2(e) of such Act (42 

23 U.S.C. 1395w–102(e)) as a non-preferred prescription 

24 drug. 

25 (c) MEDPAC STUDIES AND REPORTS.— 


jbell on DSKDVH8Z91PROD with BILLS
4 

•S 1630 IS

1 (1) STUDY AND REPORT ON THE MEDICARE

2 PART D ANTI-DISCRIMINATION CLAUSE.— 

3 (A) STUDY.—The Medicare Payment Advi4 sory Commission shall conduct a study on var5 ious aspects of the prescription drug program 

6 under part D of title XVIII of the Social Secu7 rity Act and, to the greatest extent practicable, 

8 the interaction of such program with Medicare 

9 beneficiary access to covered drugs under part 

10 B of such title. Such study shall include the fol11 lowing: 

12 (i) An analysis of— 

13 (I) the use of specialty tiers for 

14 covered part D drugs under prescrip15 tion drug plans and MA–PD plans; 

16 and 

17 (II) the effect of such specialty 

18 tiers on access to care for Medicare 

19 beneficiaries. 

20 (ii) Consideration of the mechanisms 

21 described in subparagraph (B) in the con22 text of the provisions of section 1860D– 

23 11(e)(2)(D) of the Social Security Act (42 

24 U.S.C. 1395w–111(e)(2)(D)) (in this paraVerDate Nov 24 2008 23:45 Aug 07, 2009 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1630.IS S1630

jbell on DSKDVH8Z91PROD with BILLS
5 

•S 1630 IS

1 graph referred to as the ‘‘Medicare part D 

2 anti-discrimination clause’’). 

3 (B) MECHANISMS DESCRIBED.—The fol4 lowing mechanisms are described in this sub5 paragraph: 

6 (i) The use of specialty tiers for cov7 ered part D drugs under prescription drug 

8 plans and MA–PD plans. 

9 (ii) The application of segmented co10 insurance or copayment structures to cov11 ered part D drugs based on certain cat12 egories of such drugs or diagnoses. 

13 (iii) The utilization of other differen14 tial benefit structures based on certain 

15 conditions and Medicare beneficiaries 

16 under prescription drug plans and MA–PD 

17 plans, including an analysis of the inter18 action between such utilization and the ef19 fects of such utilization with the Medicare 

20 part D anti-discrimination clause. 

21 (C) REPORT.—Not later than 1 year after 

22 the date of enactment of this Act, the Medicare 

23 Payment Advisory Commission shall submit to 

24 Congress a report containing the results of the 

25 study conducted under subparagraph (A), toVerDate Nov 24 2008 23:45 Aug 07, 2009 Jkt 079200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1630.IS S1630

jbell on DSKDVH8Z91PROD with BILLS
6 

•S 1630 IS

1 gether with recommendations for such legisla2 tion and administrative action as the Commis3 sion determines appropriate. 

4 (D) REVISED GUIDANCE.—Based on the 

5 results of the study conducted under subpara6 graph (A), the Secretary shall issue revised 

7 guidance regarding the use of mechanisms de8 scribed in subparagraph (B) to all PDP spon9 sors offering prescription drug plans under part 

10 D of title XVIII of the Social Security Act and 

11 Medicare Advantage organizations offering 

12 MA–PD plans under part C of such title. 

13 (2) STUDY AND REPORT ON COST-SHARING FOR

14 PRESCRIPTION DRUGS UNDER PARTS B AND D.— 

15 (A) STUDY.—The Medicare Payment Advi16 sory Commission shall conduct a study on cost17 sharing for prescription drugs under parts B 

18 and D of title XVIII of the Social Security Act. 

19 Such study shall include an analysis of the im20 pact of eliminating cost-sharing for covered part 

21 D drugs for Medicare beneficiaries who— 

22 (i) incur annual out-of-pocket cost23 sharing after the initial coverage limit 

24 under section 1860D–2(b)(3) of such Act 

25 (42 U.S.C. 1395w–102) that exceeds 5 


jbell on DSKDVH8Z91PROD with BILLS
7 

•S 1630 IS

1 percent of the income of the beneficiary (as 

2 determined under section 1860D– 

3 14(a)(3)(C) of such Act (42 U.S.C. 

4 1395w–114(a)(3)(C)); and 

5 (ii) do not otherwise qualify for an in6 come-related subsidy under section 

7 1860D–14(a) of such Act (42 U.S.C. 

8 1395w–114(a)) or other extra help or cost9 sharing relief. 

10 (B) REPORT.—Not later than 6 months 

11 after the date of enactment of this Act, the 

12 Medicare Payment Advisory Commission shall 

13 submit to Congress a report containing the re14 sults of the study conducted under subpara15 graph (A), together with recommendations for 

16 such legislation and administrative action as the 

17 Commission determines appropriate. 

18 (3) DEFINITIONS.—In this section: 

19 (A) COVERED PART D DRUG.—The term 

20 ‘‘covered part D drug’’ has the meaning given 

21 such term in section 1860D–2(e) of the Social 

22 Security Act (42 U.S.C. 1395w–102(e)). 

23 (B) MA–PD PLAN.—The term ‘‘MA–PD’’ 

24 plan has the meaning given such term in paraVerDate Nov 24 2008 23:45 Aug 07, 2009 Jkt 079200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1630.IS S1630

jbell on DSKDVH8Z91PROD with BILLS
8 

•S 1630 IS

1 graph (9) of section 1860D–41(a) of such Act 

2 (42 U.S.C. 1395w–151(a)). 

3 (C) MEDICARE ADVANTAGE ORGANIZA4 TION.—The term ‘‘Medicare Advantage organi5 zation’’ has the meaning given such term in 

6 section 1859(a)(1) of such Act (42 U.S.C. 

7 1395w–28(a)(1)). 

8 (D) PDP SPONSOR.—The term ‘‘PDP 

9 sponsor’’ has the meaning given such term in 

10 paragraph (13) of such section 1860D–41(a). 

11 (E) PRESCRIPTION DRUG PLAN.—The 

12 term ‘‘prescription drug plan’’ has the meaning 

13 given such term in paragraph (14) of such sec14 tion. 

15 SEC. 3. PRIVATE HEALTH INSURANCE. 

16 (a) GROUP HEALTH PLANS.— 

17 (1) PUBLIC HEALTH SERVICE ACT AMEND18 MENTS.— 

19 (A) IN GENERAL.—Subpart 2 of part A of 

20 title XXVII of the Public Health Service Act is 

21 amended by adding at the end the following 

22 new section: 


jbell on DSKDVH8Z91PROD with BILLS
9 

•S 1630 IS

1 ‘‘SEC. 2708. PROVISIONS RELATING TO PRESCRIPTION 

2 DRUGS. 

3 ‘‘(a) IN GENERAL.—A group health plan, and a 

4 health insurance issuer offering group health insurance 

5 coverage, that provides coverage for prescription drugs 

6 shall, with respect to any co-payment or coinsurance re7 quirements applicable to such drug coverage, ensure 

8 that— 

9 ‘‘(1) such required co-payment or coinsurance 

10 does not exceed the base cost of the prescription 

11 drug (as determined by the Secretary); 

12 ‘‘(2) such required co-payment or coinsurance 

13 does not exceed $200 per month for any single pre14 scription drug (30-day supply); and 

15 ‘‘(3) such required co-payment or coinsurance 

16 does not exceed, in the aggregate for all prescription 

17 drugs, $500 per month. 

18 ‘‘(b) ADJUSTMENTS.—The amounts described in 

19 paragraphs (2) and (3) of subsection (a) shall be annually 

20 adjusted to reflect the average of the percentage increase 

21 or decrease in the Consumer Price Index for all urban con22 sumers (U.S. city average) and the percentage increase 

23 or decrease in the medical care component of such Con24 sumer Price Index during the calendar year preceding the 

25 year for which the adjustment is being made. 


jbell on DSKDVH8Z91PROD with BILLS
10 

•S 1630 IS

1 ‘‘(c) NOTICE.—A group health plan under this part 

2 shall comply with the notice requirement under section 

3 714(b) of the Employee Retirement Income Security Act 

4 of 1974 with respect to the requirements of this section 

5 as if such section applied to such plan.’’. 

6 (B) CONFORMING AMENDMENT.—Section 

7 2723(c) of such Act (42 U.S.C. 300gg–23(c)) is 

8 amended by striking ‘‘section 2704’’ and insert9 ing ‘‘sections 2704 and 2708’’. 

10 (2) ERISA AMENDMENTS.— 

11 (A) IN GENERAL.—Subpart B of part 7 of 

12 subtitle B of title I of the Employee Retirement 

13 Income Security Act of 1974 is amended by 

14 adding at the end the following new section: 

15 ‘‘SEC. 715. PROVISIONS RELATING TO PRESCRIPTION 

16 DRUGS. 

17 ‘‘(a) IN GENERAL.—A group health plan, and a 

18 health insurance issuer offering group health insurance 

19 coverage, that provides coverage for prescription drugs 

20 shall, with respect to any co-payment or coinsurance re21 quirements applicable to such drug coverage, ensure 

22 that— 

23 ‘‘(1) such required co-payment or coinsurance 

24 does not exceed the base cost of the prescription 


jbell on DSKDVH8Z91PROD with BILLS
11 

•S 1630 IS

1 drug (as determined by the Secretary of Health and 

2 Human Services); 

3 ‘‘(2) such required co-payment or coinsurance 

4 does not exceed $200 per month for any single pre5 scription drug (30-day supply); and 

6 ‘‘(3) such required co-payment or coinsurance 

7 does not exceed, in the aggregate for all prescription 

8 drugs, $500 per month. 

9 ‘‘(b) ADJUSTMENTS.—The amounts described in 

10 paragraphs (2) and (3) of subsection (a) shall be annually 

11 adjusted to reflect the average of the percentage increase 

12 or decrease in the Consumer Price Index for all urban con13 sumers (U.S. city average) and the percentage increase 

14 or decrease in the medical care component of such Con15 sumer Price Index during the calendar year preceding the 

16 year for which the adjustment is being made. 

17 ‘‘(c) NOTICE.—A group health plan under this part 

18 shall comply with the notice requirement under section 

19 714(b) with respect to the requirements of this section as 

20 if such section applied to such plan.’’. 

21 (B) TABLE OF CONTENTS.—The table of 

22 contents in section 1 of such Act is amended by 

23 inserting after the item relating to section 714 

24 the following new item: 

‘‘Sec. 715. Provisions relating to prescription drugs.’’. 


jbell on DSKDVH8Z91PROD with BILLS
12 

•S 1630 IS

1 (3) INTERNAL REVENUE CODE AMEND2 MENTS.— 

3 (A) IN GENERAL.—Subchapter B of chap4 ter 100 of the Internal Revenue Code of 1986 

5 is amended by adding at the end the following 

6 new section: 

7 ‘‘SEC. 9813. PROVISIONS RELATING TO PRESCRIPTION 

8 DRUGS. 

9 ‘‘(a) IN GENERAL.—A group health plan, and a 

10 health insurance issuer offering group health insurance 

11 coverage, that provides coverage for prescription drugs 

12 shall, with respect to any co-payment or coinsurance re13 quirements applicable to such drug coverage, ensure 

14 that— 

15 ‘‘(1) such required co-payment or coinsurance 

16 does not exceed the base cost of the prescription 

17 drug (as determined by the Secretary of Health and 

18 Human Services); 

19 ‘‘(2) such required co-payment or coinsurance 

20 does not exceed $200 per month for any single pre21 scription drug (30-day supply); and 

22 ‘‘(3) such required co-payment or coinsurance 

23 does not exceed, in the aggregate for all prescription 

24 drugs, $500 per month. 


jbell on DSKDVH8Z91PROD with BILLS
13 

•S 1630 IS

1 ‘‘(b) ADJUSTMENTS.—The amounts described in 

2 paragraphs (2) and (3) of subsection (a) shall be annually 

3 adjusted to reflect the average of the percentage increase 

4 or decrease in the Consumer Price Index for all urban con5 sumers (U.S. city average) and the percentage increase 

6 or decrease in the medical care component of such Con7 sumer Price Index during the calendar year preceding the 

8 year for which the adjustment is being made. 

9 ‘‘(c) NOTICE.—A group health plan under this part 

10 shall comply with the notice requirement under section 

11 714(b) of the Employee Retirement Income Security Act 

12 of 1974 with respect to the requirements of this section 

13 as if such section applied to such plan.’’. 

14 (B) CLERICAL AMENDMENT.—The table of 

15 sections for such subchapter is amended by 

16 adding at the end the following new item: 

‘‘Sec. 9813. Provisions relating to prescription drugs.’’. 

17 (b) INDIVIDUAL HEALTH INSURANCE.— 

18 (1) IN GENERAL.—Part B of title XXVII of the 

19 Public Health Service Act is amended by inserting 

20 after section 2752 the following new section: 

21 ‘‘SEC. 2754. PROVISIONS RELATING TO PRESCRIPTION 

22 DRUGS. 

23 ‘‘The provisions of section 2708 shall apply to health 

24 insurance coverage offered by a health insurance issuer 

25 in the individual market in the same manner as they apply 


jbell on DSKDVH8Z91PROD with BILLS
14 

•S 1630 IS

1 to health insurance coverage offered by a health insurance 

2 issuer in connection with a group health plan in the small 

3 or large group market.’’. 

4 (2) CONFORMING AMENDMENT.—Section 

5 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)) 

6 is amended by striking ‘‘section 2751’’ and inserting 

7 ‘‘sections 2751 and 2754’’. 

8 (c) APPLICATION TO FEHBP.—The amendments 

9 made by this section shall apply to the administration of 

10 chapter 89 of title 5, United States Code. 

Æ 


jbell on DSKDVH8Z91PROD with BILLS