I 

113TH CONGRESS 

1ST SESSION H. R. 460 

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 

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 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 2013’’. 

4 SEC. 2. COST-SHARING REQUIREMENTS APPLICABLE TO 

5 PRESCRIPTION DRUGS IN A SPECIALTY DRUG 

6 TIER. 

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

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

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

10 ‘‘SEC. 2719B. COST-SHARING REQUIREMENTS APPLICABLE 

11 TO PRESCRIPTION DRUGS IN A SPECIALTY 

12 DRUG TIER. 

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

14 health insurance issuer offering group or individual health 

15 insurance, that provides coverage for prescription drugs 

16 and uses a formulary or other tiered cost-sharing struc17 ture shall not impose cost-sharing requirements applicable 

18 to prescription drugs in a specialty drug tier that exceed 

19 the dollar amount (or its equivalent) of cost-sharing re20 quirements applicable to prescription drugs in a non-pre21 ferred brand drug tier (or prescription drugs in a brand 

22 drug tier if there is no non-preferred brand drug tier). 

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

24 health plan or a health insurance issuer offering group or 

25 individual health insurance contains more than one non26 preferred brand drug tier, then the requirements of subVerDate Mar 15 2010 03:10 Feb 07, 2013 Jkt 029200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H460.IH H460

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1 section (a) shall be applied with respect to the non-pre2 ferred brand drug tier for which beneficiary cost-sharing 

3 is lowest. 

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

5 ‘‘(1) The term ‘cost-sharing’ includes co-pay6 ment and coinsurance. 

7 ‘‘(2) The term ‘drug tier’ means, with respect 

8 to a group health plan or health insurance issuer of9 fering group or individual health insurance coverage 

10 that uses a formulary or other cost-sharing struc11 ture, a category of drugs— 

12 ‘‘(A) within such formulary or structure 

13 for which the total dollar amount of cost-shar14 ing requirements for any drug does not vary by 

15 more than ten percent from the total dollar 

16 amount of cost-sharing requirements for any 

17 other drug; and 

18 ‘‘(B) that are prescription drugs. 

19 ‘‘(3) The term ‘non-preferred brand drug tier’ 

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

21 insurance issuer offering group or individual health 

22 insurance coverage that uses a formulary or other 

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

24 ‘‘(A) within a drug tier in such formulary 

25 or structure for which beneficiary cost-sharing 


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1 is greater than drug tiers for generic drugs or 

2 preferred brand drugs in the formulary or 

3 structure; 

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

5 ‘‘(C) that are not included within a spe6 cialty drug tier. 

7 ‘‘(4) The term ‘prescription drug’ means— 

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

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

10 ‘‘(B) includes a drug described in subpara11 graph (A) that is a biological product (as de12 fined in section 351(i) of this Act). 

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

14 respect to a group health plan or health insurance 

15 issuer offering group or individual health insurance 

16 coverage that uses a formulary or other tiered cost17 sharing structure, a category of drugs— 

18 ‘‘(A) within a drug tier in such formulary 

19 or structure for which beneficiary cost-sharing 

20 is greater than drug tiers for generic drugs, 

21 preferred brand drugs, or non-preferred drugs 

22 in the plan’s formulary; and 

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

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

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


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1 to plan years beginning on or after the date of the enact2 ment of this Act. 

Æ 


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