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[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2746 Introduced in House (IH)]

112th CONGRESS
  1st Session
                                H. R. 2746

   To amend the Employee Retirement Income Security Act of 1974, the 
  Public Health Service Act, and the Internal Revenue Code of 1986 to 
require group and individual health insurance coverage and group health 
plans to provide for coverage of oral anticancer drugs on terms no less 
  favorable than the coverage provided for intravenously administered 
                        anticancer medications.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             August 1, 2011

 Mr. Higgins introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committees on 
  Ways and Means and Education and the Workforce, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL

 
   To amend the Employee Retirement Income Security Act of 1974, the 
  Public Health Service Act, and the Internal Revenue Code of 1986 to 
require group and individual health insurance coverage and group health 
plans to provide for coverage of oral anticancer drugs on terms no less 
  favorable than the coverage provided for intravenously administered 
                        anticancer medications.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Cancer Drug Coverage Parity Act of 
2011''.

SEC. 2. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.

    (a) Employee Retirement Income Security Act of 1974 Amendments.--
(1) Subpart B of part 7 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 is amended by adding at the end 
the following new section:

``SEC. 716. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.

    ``(a) In General.--Subject to subsection (b), a group health plan, 
and a health insurance issuer providing health insurance coverage in 
connection with a group health plan, that provides benefits with 
respect to intravenously administered or injected anticancer 
medications shall provide for no less favorable coverage for 
prescribed, orally administered anticancer medication that is used to 
kill or slow the growth of cancerous cells and that has been approved 
by the Food and Drug Administration.
    ``(b) Limitation.--Subsection (a) shall only apply to anticancer 
medication that is prescribed based on a finding by the treating 
physician that the medication--
            ``(1) is medically necessary for the purpose of killing or 
        slowing the growth of cancerous cells in a manner that is in 
        accordance with nationally accepted standards of medical 
        practice;
            ``(2) is clinically appropriate in terms of type, 
        frequency, extent site, and duration; and
            ``(3) is not primarily for the convenience of the patient, 
        physician, or other health care provider.
    ``(c) Application of Cost-Sharing and Restrictions.--
            ``(1) In general.--The coverage of anticancer medication 
        under subsection (a) may be subject to annual deductibles and 
        coinsurance or copayments so long as such deductibles, 
        coinsurance, and copayments do not exceed the deductibles, 
        coinsurance, and copayments that are applicable to 
        intravenously administered or injected anticancer medications 
        under the plan or coverage for the same purpose.
            ``(2) Restriction.--A group health plan or health insurance 
        issuer may not, in order to comply with the requirement of 
        subsection (a)--
                    ``(A) impose an increase in out-of-pocket costs 
                with respect to anticancer medications; or
                    ``(B) reclassify benefits with respect to 
                anticancer medications.
    ``(d) Application of Notice, Prohibitions, Etc.--The provisions of 
subsections (b), (c), (d), and (e)(2) of section 713 shall apply with 
respect to the coverage required by subsection (a) in the same manner 
as they apply with respect to the coverage required under such section, 
except that January 1, 2012, shall be substituted for the date referred 
to in subsection (b)(3) of such section.
    ``(e) Construction.--Nothing in this section shall be construed--
            ``(1) to require the use of orally administered anticancer 
        medications as a replacement for other anticancer medications; 
        or
            ``(2) to prohibit a group health plan or health insurance 
        issuer from requiring prior authorization or imposing other 
        appropriate utilization controls in approving coverage for any 
        chemotherapy.''.
    (2) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by 
striking ``section 711'' and inserting ``sections 711 and 716''.
    (3) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by 
striking ``section 711'' and inserting ``sections 711 and 716''.
    (4) The table of contents in section 1 of such Act is amended by 
inserting after the item relating to section 714 the following new 
items:

``Sec. 715. Additional market reforms.
``Sec. 716. Parity in coverage for oral anticancer drugs.''.
    (b) Public Health Service Act Amendments.--(1) Title XXVII of the 
Public Health Service Act is amended by inserting after section 2728 
(42 U.S.C. 300gg-28), as redesignated by section 1001(2) of the Patient 
Protection and Affordable Care Act (Public Law 111-148), the following 
new section:

``SEC. 2729. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.

    ``(a) In General.--Subject to subsection (b), a group health plan, 
and a health insurance issuer offering group or individual health 
insurance coverage, that provides benefits with respect to 
intravenously administered or injected anticancer medications shall 
provide for no less favorable coverage for prescribed, orally 
administered anticancer medication that is used to kill or slow the 
growth of cancerous cells and that has been approved by the Food and 
Drug Administration.
    ``(b) Limitation.--Subsection (a) shall only apply to anticancer 
medication that is prescribed based on a finding by the treating 
physician that the medication--
            ``(1) is medically necessary for the purpose of killing or 
        slowing the growth of cancerous cells in a manner that is in 
        accordance with nationally accepted standards of medical 
        practice;
            ``(2) is clinically appropriate in terms of type, 
        frequency, extent site, and duration; and
            ``(3) is not primarily for the convenience of the patient, 
        physician, or other health care provider.
    ``(c) Application of Cost-Sharing and Restrictions.--
            ``(1) In general.--The coverage of anticancer medication 
        under subsection (a) may be subject to annual deductibles and 
        coinsurance or copayments so long as such deductibles, 
        coinsurance, and copayments do not exceed the deductibles, 
        coinsurance, and copayments that are applicable to 
        intravenously administered or injected anticancer medications 
        under the plan or coverage for the same purpose.
            ``(2) Restriction.--A group health plan or health insurance 
        issuer may not, in order to comply with the requirement of 
        subsection (a)--
                    ``(A) impose an increase in out-of-pocket costs 
                with respect to anticancer medications; or
                    ``(B) reclassify benefits with respect to 
                anticancer medications.
    ``(d) Application of Notice, Prohibitions, Etc.--The provisions of 
subsections (b), (c), (d), and (e)(2) of section 713 of the Employee 
Retirement and Income Security Act of 1974 shall apply with respect to 
the coverage required by subsection (a) in the same manner as they 
apply with respect to the coverage required under such section, except 
that January 1, 2012, shall be substituted for the date referred to in 
subsection (b)(3) of such section.
    ``(e) Construction.--Nothing in this section shall be construed--
            ``(1) to require the use of orally administered anticancer 
        medications as a replacement for other anticancer medications; 
        or
            ``(2) to prohibit a group health plan or health insurance 
        issuer from requiring prior authorization or imposing other 
        appropriate utilization controls in approving coverage for any 
        chemotherapy.''.
    (2) Section 2724(c) of such Act (42 U.S.C. 300gg-23(c)), as 
redesignated by section 1001(4) and subsection (c)(14) of the section 
1563 (relating to conforming amendments) of Public Law 111-148, is 
amended by striking ``section 2704'' and inserting ``sections 2725 and 
2729''.
    (3) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-62(b)(2)) is 
amended by striking ``section 2751'' and inserting ``sections 2751 and 
2729''.
    (4) For purposes of applying section 2729 of the Public Health 
Service Act, as inserted by paragraph (1), to individual health 
insurance coverage before 2014, the provisions of such section shall be 
treated as also included under part B of title XXVII of the Public 
Health Service Act.
    (c) Internal Revenue Code Amendments.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986, as amended by subsection (f) of 
        the section 1563 (relating to conforming amendments) of Public 
        Law 111-148, is amended by adding at the end the following new 
        section:

``SEC. 9816. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.

    ``(a) In General.--Subject to subsection (b), a group health plan 
that provides benefits with respect to intravenously administered or 
injected anticancer medications shall provide for no less favorable 
coverage for prescribed, orally administered anticancer medication that 
is used to kill or slow the growth of cancerous cells and that has been 
approved by the Food and Drug Administration.
    ``(b) Limitation.--Subsection (a) shall only apply to anticancer 
medication that is prescribed based on a finding by the treating 
physician that the medication--
            ``(1) is medically necessary for the purpose of killing or 
        slowing the growth of cancerous cells in a manner that is in 
        accordance with nationally accepted standards of medical 
        practice;
            ``(2) is clinically appropriate in terms of type, 
        frequency, extent site, and duration; and
            ``(3) is not primarily for the convenience of the patient, 
        physician, or other health care provider.
    ``(c) Application of Cost-Sharing and Restrictions.--
            ``(1) In general.--The coverage of anticancer medication 
        under subsection (a) may be subject to annual deductibles and 
        coinsurance or copayments so long as such deductibles, 
        coinsurance, and copayments do not exceed the deductibles, 
        coinsurance, and copayments that are applicable to 
        intravenously administered or injected anticancer medications 
        under the plan for the same purpose.
            ``(2) Restriction.--A group health plan may not, in order 
        to comply with the requirement of subsection (a)--
                    ``(A) impose an increase in out-of-pocket costs 
                with respect to anticancer medications; or
                    ``(B) reclassify benefits with respect to 
                anticancer medications.
    ``(d) Application of Notice, Prohibitions, Etc.--The provisions of 
subsections (b), (c), (d), and (e)(2) of section 713 of the Employee 
Retirement and Income Security Act of 1974 shall apply with respect to 
the coverage required by subsection (a) in the same manner as they 
apply with respect to the coverage required under such section, except 
that January 1, 2012, shall be substituted for the date referred to in 
subsection (b)(3) of such section.
    ``(e) Construction.--Nothing in this section shall be construed--
            ``(1) to require the use of orally administered anticancer 
        medications as a replacement for other anticancer medications; 
        or
            ``(2) to prohibit a group health plan or health insurance 
        issuer from requiring prior authorization or imposing other 
        appropriate utilization controls in approving coverage for any 
        chemotherapy.''.
            (2) Clerical amendment.--The table of sections for such 
        subchapter is amended by adding at the end the following new 
        items:

``Sec. 9815. Additional market reforms.
``Sec. 9816. Parity in coverage for oral anticancer drugs.''.
    (d) Clarifying Amendment Regarding Application to Grandfathered 
Plans.--Section 1251(a)(4)(A) of the Patient Protection and Affordable 
Care Act (Public Law 111-148; 42 U.S.C. 18011(a)(4)(A)), as added by 
section 2301(a) of Public Law 111-152, is amended by adding at the end 
the following new clause:
                            ``(v) Section 2729 (relating to standards 
                        relating to benefits for minor child's 
                        congenital or developmental deformity or 
                        disorder), as added by section 2(b) of the 
                        Cancer Drug Coverage Parity Act of 2011.''.
    (e) Effective Date.--The amendments made by this section shall 
apply with respect to group health plans for plan years beginning on or 
after January 1, 2012, and with respect to health insurance coverage 
offered, sold, issued, renewed, in effect, or operated in the 
individual market on or after such date.
    (f) Study.--Not later than 2 years after the date of the enactment 
of this Act--
            (1) the Medicare Payment Advisory Commission shall complete 
        a study that assesses how closing the Medicare part D donut 
        hole under the amendments made by section 3301 of the Patient 
        Protection and Affordable Care Act (Public Law 111-148), as 
        amended by section 1101 of the Health Care and Education 
        Reconciliation Act of 2010 (Public Law 111-152), affects 
        Medicare coverage for orally administered anticancer 
        medications, with a particular focus on cost and accessibility; 
        and
            (2) submit a report to Congress on the results of such 
        study.
                                 <all>
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