I
105TH CONGRESS
2D SESSION
H. R. 4559
To assure equitable treatment in health care coverage of prescription drugs
under group health plans, health insurance coverage, Medicare and Med-
icaid managed care arrangements, medigap insurance coverage, and
health plans under the Federal employees’ health benefits program.
IN THE HOUSE OF REPRESENTATIVES
SEPTEMBER 14, 1998
Mr. BROWN of Ohio introduced the following bill; which was referred to the
Committee on Commerce, and in addition to the Committees on Ways
and Means, Education and the Workforce, and Government Reform and
Oversight, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the jurisdic-
tion of the committee concerned
A BILL
To assure equitable treatment in health care coverage of
prescription drugs under group health plans, health in-
surance coverage, Medicare and Medicaid managed care
arrangements, medigap insurance coverage, and health
plans under the Federal employees’ health benefits pro-
gram.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Prescription Drug Pa-
tient Choice Act of 1998’’.
SEC. 2. EQUITY IN PROVISION OF PRESCRIPTION DRUG
COVERAGE.
(a) GROUP HEALTH PLANS.—
(1) PUBLIC
HEALTH
SERVICE
ACT
AMEND-
MENTS.—(A) Subpart 2 of part A of title XXVII of
the Public Health Service Act is amended by adding
at the end the following new section:
‘‘SEC. 2706. EQUITY IN PROVISION OF PRESCRIPTION DRUG
COVERAGE.
‘‘(a) EQUITY IN PROVISION OF PRESCRIPTION DRUG
COVERAGE.—
‘‘(1) IN GENERAL.—If a group health plan or
a health insurance issuer offering group health in-
surance coverage provides for prescription drug cov-
erage only if such drugs are furnished through pro-
viders who are members of a network of providers
who have entered into a contract with the plan or
issuer to provide such drugs, the issuer shall also
offer to enrollees the option of health insurance cov-
erage which provides for coverage of such drugs
which are not furnished through providers who are
members of such network.
‘‘(2) PREMIUMS.—A group health plan or a
health insurance issuer offering group health insur-
ance coverage may not charge a higher premium, co-
payment, or deductible for coverage of drugs which
are furnished through providers who are not mem-
bers of a network of providers who have entered into
a contract with the plan or issuer.
‘‘(3) COST
SHARING.—Under the option de-
scribed in paragraph (1), the health insurance cov-
erage shall provide for reimbursement rates for pre-
scription coverage offered by nonparticipating pro-
viders that are not less than the reimbursement
rates for prescription coverage offered by participat-
ing pharmacies.
‘‘(b) CONSTRUCTION.—Nothing in this section shall
be construed as preventing a plan or issuer from—
‘‘(1) restricting the drugs for which benefits are
provided under the plan or health insurance cov-
erage, or
‘‘(2) imposing a limitation on the amount of
benefits provided with respect to such coverage or
the cost sharing that may be imposed with respect
to such coverage,
so long as such restrictions and limitations are consistent
with subsection (a).
‘‘(c) NOTICE.—A group health plan under this part
shall comply with the notice requirement under section
713(d) 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) Section 2723(c) of such Act (42 U.S.C.
300gg–23(c)) is amended by striking ‘‘section 2704’’
and inserting ‘‘sections 2704 and 2706’’.
(2) ERISA AMENDMENTS.—(A) Subpart B of
part 7 of subtitle B of title I of the Employee Re-
tirement Income Security Act of 1974 is amended by
adding at the end the following new section:
‘‘SEC. 713. EQUITY IN PROVISION OF PRESCRIPTION DRUG
COVERAGE.
‘‘(a) EQUITY IN PROVISION OF PRESCRIPTION DRUG
COVERAGE.—
‘‘(1) IN GENERAL.—If a group health plan or
a health insurance issuer offering group health in-
surance coverage provides for prescription drug cov-
erage only if such drugs are furnished through pro-
viders who are members of a network of providers
who have entered into a contract with the issuer to
provide such drugs, the issuer shall also offer to
such enrollees the option of health insurance cov-
erage which provides for coverage of such drugs
which are not furnished through providers who are
members of such network.
‘‘(2) PREMIUMS.—A group health plan or a
health insurance issuer offering group health insur-
ance coverage may not charge a higher premium, co-
payment, or deductible for coverage of drugs which
are furnished through providers who are not mem-
bers of a network of providers who have entered into
a contract with the plan or issuer.
‘‘(3) COST
SHARING.—Under the option de-
scribed in paragraph (1), the health insurance cov-
erage shall provide for reimbursement rates for pre-
scription coverage offered by non participating pro-
viders that are not less than the reimbursement
rates for prescription coverage offered by participat-
ing pharmacies.
‘‘(b) CONSTRUCTION.—Nothing in this section shall
be construed as preventing a plan or issuer from—
‘‘(1) restricting the drugs for which benefits are
provided under the plan or health insurance cov-
erage, or
‘‘(2) imposing a limitation on the amount of
benefits provided with respect to such coverage or
the cost sharing that may be imposed with respect
to such coverage,
so long as such restrictions and limitations are consistent
with subsection (a).
‘‘(c) NOTICE UNDER GROUP HEALTH PLAN.—The
imposition of the requirements of this section shall be
treated as a material modification in the terms of the plan
described in section 102(a)(1), for purposes of assuring
notice of such requirements under the plan; except that
the summary description required to be provided under the
last sentence of section 104(b)(1) with respect to such
modification shall be provided by not later than 60 days
after the first day of the first plan year in which such
requirements apply.’’.
(B) Section 731(c) of such Act (29 U.S.C.
1191(c)) is amended by striking ‘‘section 711’’ and
inserting ‘‘sections 711 and 713’’.
(C) Section 732(a) of such Act (29 U.S.C.
1191a(a)) is amended by striking ‘‘section 711’’ and
inserting ‘‘sections 711 and 713’’.
(D) The table of contents in section 1 of such
Act is amended by inserting after the item relating
to section 712 the following new item:
‘‘Sec. 713. Equity in provision of prescription drug coverage.’’.
(b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B
of title XXVII of the Public Health Service Act is amend-
ed by inserting after section 2751 the following new sec-
tion:
‘‘SEC. 2752. EQUITY IN PROVISION OF PRESCRIPTION DRUG
COVERAGE.
‘‘(a) IN GENERAL.—The provisions of section 2706
(other than subsection (c)) shall apply to health insurance
coverage offered by a health insurance issuer in the indi-
vidual market in the same manner as it applies to health
insurance coverage offered by a health insurance issuer
in connection with a group health plan in the small or
large group market.
‘‘(b) NOTICE.—A health insurance issuer under this
part shall comply with the notice requirement under sec-
tion 713(c) of the Employee Retirement Income Security
Act of 1974 with respect to the requirements referred to
in subsection (a) as if such section applied to such issuer
and such issuer were a group health plan.’’.
(2) 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 2752’’.
(c) APPLICATION
TO MEDICARE MANAGED CARE
PLANS.—Subparagraph (B) of section 1876(c)(4) of the
Social Security Act (42 U.S.C. 1395mm(c)(4)) is amended
to read as follows:
‘‘(B) meets the requirements of section 2752 of
the Public Health Service Act with respect to indi-
viduals enrolled with the organization under this sec-
tion.’’.
(d) APPLICATION
TO MEDICAID MANAGED CARE
PLANS.—Title XIX of such Act (42 U.S.C. 1396 et seq.)
is amended by inserting after section 1908 the following
new section:
‘‘EQUITY IN PROVISION OF PRESCRIPTION DRUG
COVERAGE
‘‘SEC. 1909. (a) IN GENERAL.—A State plan may
not be approved under this title, and Federal financial
participation not available under section 1903(a) with re-
spect to such a plan, unless the plan requires each health
insurance issuer or other entity with a contract with such
plan to provide coverage or benefits to individuals eligible
for medical assistance under the plan to comply with the
provisions of section 2752 of the Public Health Service
Act with respect to such coverage or benefits.
‘‘(b) WAIVERS PROHIBITED.—The requirement of
subsection (a) may not be waived under section 1115 or
section 1915(b) of the Social Security Act.’’.
(e) MEDIGAP AND MEDICARE SELECT POLICIES.—
Section 1882 of such Act (42 U.S.C. 1395ss) is amend-
ed—
(1) in subsection (s)(2), by adding at the end
the following new subparagraph:
‘‘(E) An issuer of a medicare supplemental policy (as
defined in section 1882(g)) shall comply with the require-
ments of section 2752 of the Public Health Service Act
with respect to benefits offered under such policy.’’; and
(2) in subsection (t)(1)—
(A) in subparagraph (B), by inserting
‘‘subject to subparagraph (G),’’ after ‘‘(B)’’,
(B) by striking ‘‘and’’ at the end of sub-
paragraph (E),
(C) by striking the period at the end of
subparagraph (F) and inserting ‘‘; and’’, and
(D) by adding at the end the following new
subparagraph:
‘‘(G) the issuer of the policy complies with the
requirements of section 2752 of the Public Health
Service Act with respect to enrollees under this sub-
section .’’.
(f) FEHBP.—Section 8902 of title 5, United States
Code, is amended by adding at the end the following the
following new subsection:
‘‘(o) A contract may not be made or a plan approved
which excludes does not comply with the requirements of
section 2752 of the Public Health Service Act.’’.
(g) EFFECTIVE DATES.—(1)(A) Subject to subpara-
graph (B), the amendments made by subsection (a) shall
apply with respect to group health plans for plan years
beginning on or after January 1, 1998.
(B) In the case of a group health plan maintained
pursuant to 1 or more collective bargaining agreements
between employee representatives and 1 or more employ-
ers that is ratified before the date of enactment of this
Act, the amendments made by subsection (a) shall not
apply to plan years beginning before the later of—
(i) the date on which the last collective bargain-
ing agreements relating to the plan terminates (de-
termined without regard to any extension thereof
agreed to after the date of enactment of this Act),
or
(ii) January 1, 1998.
For purposes of clause (i), any plan amendment made pur-
suant to a collective bargaining agreement relating to the
plan which amends the plan solely to conform to any re-
quirement added by subsection (a) shall not be treated as
a termination of such collective bargaining agreement.
(2) The amendments made by subsection (b) shall
apply with respect to health insurance coverage offered,
sold, issued, renewed, in effect, or operated in the individ-
ual market on or after January 1, 1998.
(3) The amendment made by subsection (c) shall
apply to contracts for contract periods beginning on or
after January 1, 1998.
(4) The amendment made by subsection (d) shall
apply to Federal financial participation for State plan ex-
penditures made on or after January 1, 1998.
(5) The amendments made by subsection (e) shall
apply with respect to medicare supplemental policies and
medicare select policies offered, sold, issued, renewed, in
effect, or operated on and after January 1, 1998.
(6) The amendment made by subsection (f) shall
apply with respect to contracts for periods beginning on
and after January 1, 1998.
(h) COORDINATED REGULATIONS.—Section 104(1)
of Health Insurance Portability and Accountability Act of
1996 is amended by striking ‘‘this subtitle (and the
amendments made by this subtitle and section 401)’’ and
inserting ‘‘the provisions of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of
1974, and the provisions of parts A and C of title XXVII
of the Public Health Service Act’’.
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