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 spe-
cialty 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 pur-
poses. 
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 ‘‘Patients’ Access to 
Treatments Act of 2012’’. 
SEC. 2. CO-PAYMENT, COINSURANCE, AND OTHER COST- 
SHARING REQUIREMENTS APPLICABLE TO 
PRESCRIPTION DRUGS IN A SPECIALTY DRUG 
TIER. 
(a) IN GENERAL.—Subpart II of part A of title 
XXVII of the Public Health Service Act (42 U.S.C. 300gg 
et seq.) is amended by adding at the end the following: 
‘‘SEC. 2719B. CO-PAYMENT, COINSURANCE, AND OTHER 
COST-SHARING REQUIREMENTS APPLICABLE 
TO PRESCRIPTION DRUGS IN A SPECIALTY 
DRUG TIER. 
‘‘(a) REQUIREMENT.—A group health plan, or a 
health insurance issuer offering group or individual health 
insurance, that provides coverage for prescription drugs 
and uses a formulary or other tiered cost-sharing struc-
ture shall not impose co-payment, coinsurance, or other 
cost-sharing requirements applicable to prescription drugs 
in a specialty drug tier that exceed the dollar amount (or 
its equivalent) of co-payment, coinsurance, or other cost- 
sharing requirements applicable to prescription drugs in 
a non-preferred brand drug tier (or prescription drugs in 
a brand drug tier if there is no non-preferred brand drug 
tier). 
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‘‘(b) SPECIAL RULE.—If a formulary used by a group 
health plan or a health insurance issuer offering group or 
individual health insurance contains more than one non- 
preferred brand drug tier, then the requirements of sub-
section (a) shall be applied with respect to the non-pre-
ferred brand drug tier for which beneficiary cost-sharing 
is lowest. 
‘‘(c) DEFINITIONS.—In this section: 
‘‘(1) The term ‘prescription drug’ means— 
‘‘(A) a drug subject to section 503(b)(1) of 
the Federal Food, Drug, or Cosmetic Act; and 
‘‘(B) includes a drug described in subpara-
graph (A) that is a biological product (as de-
fined in section 351(i) of this Act). 
‘‘(2) The term ‘non-preferred brand drug tier’ 
means, with respect to a group health plan or health 
insurance issuer offering group or individual health 
insurance coverage that uses a formulary or other 
tiered cost-sharing structure, a category of drugs— 
‘‘(A) within a tier in such formulary for 
which beneficiary cost-sharing is greater than 
tiers for generic drugs or preferred brand drugs 
in the plan’s formulary; 
‘‘(B) that are prescription drugs; and 
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‘‘(C) that are not included within a spe-
cialty drug tier. 
‘‘(3) The term ‘specialty drug tier’ means, with 
respect to a group health plan or health insurance 
issuer offering group or individual health insurance 
coverage that uses a formulary or other tiered cost- 
sharing structure, a category of drugs— 
‘‘(A) within a tier in such formulary for 
which beneficiary cost-sharing is greater than 
tiers for generic drugs, preferred brand drugs, 
or non-preferred drugs in the plan’s formulary; 
and 
‘‘(B) that are prescription drugs.’’. 
(b) EFFECTIVE DATE.—Section 2719B of the Public 
Health Service Act, as added by subsection (a), applies 
to plan years beginning on or after the date of the enact-
ment of this Act. 
Æ 
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