I 
111TH CONGRESS 
1ST SESSION H. R. 3799 
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 HOUSE OF REPRESENTATIVES 
OCTOBER 13, 2009 
Mr. JOHNSON of Georgia (for himself, Ms. KILROY, Mr. CARNAHAN, Mr. 
RYAN of Ohio, Ms. LEE of California, Mr. ELLISON, Mr. DOGGETT, Ms. 
FUDGE, and Mr. KENNEDY) introduced the following bill; which was re-
ferred to the Committee on Energy and Commerce, and in addition to 
the Committees on Ways and Means and Education and Labor, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
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 Inter-
nal Revenue Code of 1986, to improve prescription drug 
coverage under private health insurance, and for other 
purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Affordable Access to 
Prescription Medications Act of 2009’’. 
SEC. 2. MEDICARE PART D PRESCRIPTION DRUG PLANS. 
(a) IN GENERAL.—Section 1860D–2(b)(4) of the So-
cial Security Act (42 U.S.C. 1395w–102(b)(4)) is amend-
ed by adding at the end the following new subparagraph: 
‘‘(E) ADDITIONAL PROTECTIONS.— 
‘‘(i) IN
GENERAL.—Notwithstanding 
any other provision of this part, effective 
for plan years beginning on or after Janu-
ary 1, 2011, a PDP sponsor of a prescrip-
tion drug plan and an MA organization of-
fering an MA–PD plan shall, with respect 
to any co-payment or coinsurance require-
ments applicable to covered part D drugs 
under the plan, ensure that— 
‘‘(I) such required co-payment or 
coinsurance does not exceed the base 
cost of the covered part D drug (as 
determined by the Secretary); 
‘‘(II) such required co-payment 
or coinsurance does not exceed $200 
per month for any single covered part 
D drug (30-day supply); and 
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‘‘(III) such required co-payment 
or coinsurance does not exceed, in the 
aggregate for all covered part D 
drugs, $500 per month. 
‘‘(ii) ADJUSTMENTS.—The amounts 
described in clauses (II) and (III) of clause 
(i) shall be annually adjusted to reflect the 
average of the percentage increase or de-
crease in the Consumer Price Index for all 
urban consumers (U.S. city average) and 
the percentage increase or decrease in the 
medical care component of such Consumer 
Price Index during the calendar year pre-
ceding the year for which the adjustment 
is being made.’’. 
(b) EXPANSION OF EXCEPTIONS PROCESS.—Effec-
tive for plan years beginning on or after January 1, 2011, 
the Secretary shall expand the formulary tier exception re-
quest process under sections 423.560 through 423.636 of 
title 42, Code of Federal Regulations (as in effect on the 
date of enactment of this Act), to allow individuals en-
rolled in a prescription drug plan under part D of title 
XVIII of the Social Security Act or an MA–PD plan under 
part C of such title to request an exception for a specialty 
prescription drug to a plan’s designation of a covered part 
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text of the provisions of section 1860D– 
11(e)(2)(D) of the Social Security Act (42 
U.S.C. 1395w–111(e)(2)(D)) (in this para-
graph referred to as the ‘‘Medicare part D 
anti-discrimination clause’’). 
(B) MECHANISMS
DESCRIBED.—The fol-
lowing mechanisms are described in this sub-
paragraph: 
(i) The use of specialty tiers for cov-
ered part D drugs under prescription drug 
plans and MA–PD plans. 
(ii) The application of segmented co-
insurance or copayment structures to cov-
ered part D drugs based on certain cat-
egories of such drugs or diagnoses. 
(iii) The utilization of other differen-
tial benefit structures based on certain 
conditions 
and 
Medicare 
beneficiaries 
under prescription drug plans and MA–PD 
plans, including an analysis of the inter-
action between such utilization and the ef-
fects of such utilization with the Medicare 
part D anti-discrimination clause. 
(C) REPORT.—Not later than 1 year after 
the date of enactment of this Act, the Medicare 
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Payment Advisory Commission shall submit to 
Congress a report containing the results of the 
study conducted under subparagraph (A), to-
gether with recommendations for such legisla-
tion and administrative action as the Commis-
sion determines appropriate. 
(D) REVISED
GUIDANCE.—Based on the 
results of the study conducted under subpara-
graph (A), the Secretary shall issue revised 
guidance regarding the use of mechanisms de-
scribed in subparagraph (B) to all PDP spon-
sors offering prescription drug plans under part 
D of title XVIII of the Social Security Act and 
Medicare 
Advantage 
organizations 
offering 
MA–PD plans under part C of such title. 
(2) STUDY AND REPORT ON COST-SHARING FOR 
PRESCRIPTION DRUGS UNDER PARTS B AND D.— 
(A) STUDY.—The Medicare Payment Advi-
sory Commission shall conduct a study on cost- 
sharing for prescription drugs under parts B 
and D of title XVIII of the Social Security Act. 
Such study shall include an analysis of the im-
pact of eliminating cost-sharing for covered part 
D drugs for Medicare beneficiaries who— 
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(i) incur annual out-of-pocket cost- 
sharing after the initial coverage limit 
under section 1860D–2(b)(3) of such Act 
(42 U.S.C. 1395w–102) that exceeds 5 
percent of the income of the beneficiary (as 
determined 
under 
section 
1860D– 
14(a)(3)(C) of such Act (42 U.S.C. 
1395w–114(a)(3)(C)); and 
(ii) do not otherwise qualify for an in-
come-related 
subsidy 
under 
section 
1860D–14(a) of such Act (42 U.S.C. 
1395w–114(a)) or other extra help or cost- 
sharing relief. 
(B) REPORT.—Not later than 6 months 
after the date of enactment of this Act, the 
Medicare Payment Advisory Commission shall 
submit to Congress a report containing the re-
sults of the study conducted under subpara-
graph (A), together with recommendations for 
such legislation and administrative action as the 
Commission determines appropriate. 
(3) DEFINITIONS.—In this section: 
(A) COVERED PART D DRUG.—The term 
‘‘covered part D drug’’ has the meaning given 
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such term in section 1860D–2(e) of the Social 
Security Act (42 U.S.C. 1395w–102(e)). 
(B) MA–PD PLAN.—The term ‘‘MA–PD’’ 
plan has the meaning given such term in para-
graph (9) of section 1860D–41(a) of such Act 
(42 U.S.C. 1395w–151(a)). 
(C) MEDICARE
ADVANTAGE
ORGANIZA-
TION.—The term ‘‘Medicare Advantage organi-
zation’’ has the meaning given such term in 
section 1859(a)(1) of such Act (42 U.S.C. 
1395w–28(a)(1)). 
(D) PDP
SPONSOR.—The term ‘‘PDP 
sponsor’’ has the meaning given such term in 
paragraph (13) of such section 1860D–41(a). 
(E) PRESCRIPTION
DRUG
PLAN.—The 
term ‘‘prescription drug plan’’ has the meaning 
given such term in paragraph (14) of such sec-
tion. 
SEC. 3. PRIVATE HEALTH INSURANCE. 
(a) GROUP HEALTH PLANS.— 
(1) PUBLIC
HEALTH
SERVICE
ACT
AMEND-
MENTS.— 
(A) IN GENERAL.—Subpart 2 of part A of 
title XXVII of the Public Health Service Act is 
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amended by adding at the end the following 
new section: 
‘‘SEC. 2708. PROVISIONS RELATING TO PRESCRIPTION 
DRUGS. 
‘‘(a) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group health insurance 
coverage, that provides coverage for prescription drugs 
shall, with respect to any co-payment or coinsurance re-
quirements applicable to such drug coverage, ensure 
that— 
‘‘(1) such required co-payment or coinsurance 
does not exceed the base cost of the prescription 
drug (as determined by the Secretary); 
‘‘(2) such required co-payment or coinsurance 
does not exceed $200 per month for any single pre-
scription drug (30-day supply); and 
‘‘(3) such required co-payment or coinsurance 
does not exceed, in the aggregate for all prescription 
drugs, $500 per month. 
‘‘(b) ADJUSTMENTS.—The amounts described in 
paragraphs (2) and (3) of subsection (a) shall be annually 
adjusted to reflect the average of the percentage increase 
or decrease in the Consumer Price Index for all urban con-
sumers (U.S. city average) and the percentage increase 
or decrease in the medical care component of such Con-
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sumer Price Index during the calendar year preceding the 
year for which the adjustment is being made. 
‘‘(c) NOTICE.—A group health plan under this part 
shall comply with the notice requirement under section 
714(b) of the Employee Retirement Income Security Act 
of 1974 with respect to the requirements of this section 
as if such section applied to such plan.’’. 
(B) CONFORMING
AMENDMENT.—Section 
2723(c) of such Act (42 U.S.C. 300gg–23(c)) is 
amended by striking ‘‘section 2704’’ and insert-
ing ‘‘sections 2704 and 2708’’. 
(2) ERISA AMENDMENTS.— 
(A) IN GENERAL.—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. 
715. 
PROVISIONS 
RELATING 
TO 
PRESCRIPTION 
DRUGS. 
‘‘(a) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group health insurance 
coverage, that provides coverage for prescription drugs 
shall, with respect to any co-payment or coinsurance re-
quirements applicable to such drug coverage, ensure 
that— 
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‘‘(1) such required co-payment or coinsurance 
does not exceed the base cost of the prescription 
drug (as determined by the Secretary of Health and 
Human Services); 
‘‘(2) such required co-payment or coinsurance 
does not exceed $200 per month for any single pre-
scription drug (30-day supply); and 
‘‘(3) such required co-payment or coinsurance 
does not exceed, in the aggregate for all prescription 
drugs, $500 per month. 
‘‘(b) ADJUSTMENTS.—The amounts described in 
paragraphs (2) and (3) of subsection (a) shall be annually 
adjusted to reflect the average of the percentage increase 
or decrease in the Consumer Price Index for all urban con-
sumers (U.S. city average) and the percentage increase 
or decrease in the medical care component of such Con-
sumer Price Index during the calendar year preceding the 
year for which the adjustment is being made. 
‘‘(c) NOTICE.—A group health plan under this part 
shall comply with the notice requirement under section 
714(b) with respect to the requirements of this section as 
if such section applied to such plan.’’. 
(B) TABLE OF CONTENTS.—The table of 
contents in section 1 of such Act is amended by 
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inserting after the item relating to section 714 
the following new item: 
‘‘Sec. 715. Provisions relating to prescription drugs.’’. 
(3) 
INTERNAL
REVENUE
CODE
AMEND-
MENTS.— 
(A) IN GENERAL.—Subchapter B of chap-
ter 100 of the Internal Revenue Code of 1986 
is amended by adding at the end the following 
new section: 
‘‘SEC. 9813. PROVISIONS RELATING TO PRESCRIPTION 
DRUGS. 
‘‘(a) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group health insurance 
coverage, that provides coverage for prescription drugs 
shall, with respect to any co-payment or coinsurance re-
quirements applicable to such drug coverage, ensure 
that— 
‘‘(1) such required co-payment or coinsurance 
does not exceed the base cost of the prescription 
drug (as determined by the Secretary of Health and 
Human Services); 
‘‘(2) such required co-payment or coinsurance 
does not exceed $200 per month for any single pre-
scription drug (30-day supply); and 
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‘‘(3) such required co-payment or coinsurance 
does not exceed, in the aggregate for all prescription 
drugs, $500 per month. 
‘‘(b) ADJUSTMENTS.—The amounts described in 
paragraphs (2) and (3) of subsection (a) shall be annually 
adjusted to reflect the average of the percentage increase 
or decrease in the Consumer Price Index for all urban con-
sumers (U.S. city average) and the percentage increase 
or decrease in the medical care component of such Con-
sumer Price Index during the calendar year preceding the 
year for which the adjustment is being made. 
‘‘(c) NOTICE.—A group health plan under this part 
shall comply with the notice requirement under section 
714(b) of the Employee Retirement Income Security Act 
of 1974 with respect to the requirements of this section 
as if such section applied to such plan.’’. 
(B) CLERICAL AMENDMENT.—The table of 
sections for such subchapter is amended by 
adding at the end the following new item: 
‘‘Sec. 9813. Provisions relating to prescription drugs.’’. 
(b) INDIVIDUAL HEALTH INSURANCE.— 
(1) IN GENERAL.—Part B of title XXVII of the 
Public Health Service Act is amended by inserting 
after section 2752 the following new section: 
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‘‘SEC. 2754. PROVISIONS RELATING TO PRESCRIPTION 
DRUGS. 
‘‘The provisions of section 2708 shall apply to health 
insurance coverage offered by a health insurance issuer 
in the individual market in the same manner as they apply 
to health insurance coverage offered by a health insurance 
issuer in connection with a group health plan in the small 
or large group market.’’. 
(2) 
CONFORMING
AMENDMENT.—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 2754’’. 
(c) APPLICATION
TO FEHBP.—The amendments 
made by this section shall apply to the administration of 
chapter 89 of title 5, United States Code. 
Æ 
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