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108th CONGRESS
1st Session
H. R. 1243
To assure equitable treatment in health care coverage of prescription
drugs under group health plans, health insurance coverage, Medicare and
Medicaid managed care arrangements, Medigap insurance coverage, and
health plans under the Federal employees' health benefits program
(FEHBP).
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 12, 2003
Mrs. Lowey (for herself, Mr. McNulty, Mr. Berry, Ms. Woolsey, Mr.
Rothman, Mr. Davis of Illinois, Ms. Watson, Mr. Sanders, Mr. Emanuel,
Ms. Carson of Indiana, and Mr. Pallone) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committees on Ways and Means, Education and the
Workforce, and Government Reform, 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 assure equitable treatment in health care coverage of prescription
drugs under group health plans, health insurance coverage, Medicare and
Medicaid managed care arrangements, Medigap insurance coverage, and
health plans under the Federal employees' health benefits program
(FEHBP).
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 ``Prescription Drug Benefit Equity Act
of 2003''.
SEC. 2. EQUITY IN PROVISION OF PRESCRIPTION DRUG COVERAGE.
(a) Group Health Plans.--
(1) Public health service act amendments.--(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. 2707. EQUITY IN PROVISION OF PRESCRIPTION DRUG COVERAGE.
``(a) Equity in Provision of Prescription Drug Coverage.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage, that
provides for mail-order prescription drug coverage (as defined
in paragraph (3)(A)) shall also provide non-mail-order
prescription drug coverage consistent with paragraph (2).
``(2) Equitable coverage.--A plan or coverage provides non-
mail-order prescription drug coverage consistent with this
paragraph only if--
``(A) benefits under the non-mail-order
prescription coverage are provided for in the case of
all drugs and all circumstances under which benefits
are provided under the mail-order prescription drug
coverage;
``(B) no deductible or similar cost-sharing is
imposed with respect to benefits under the non-mail-
order prescription drug coverage unless such a
deductible or similar cost-sharing is imposed with
respect to benefits under the mail-order prescription
drug coverage; and
``(C) the benefits for the non-mail-order coverage
assures payments consistent with either (or both) of
the following clauses:
``(i) The dollar amount of payment for
prescription drug coverage is not less than the
dollar amount of benefits provided with respect
to the mail-order coverage for that same
coverage.
``(ii) The cost-sharing (including
deductibles, copayments, or coinsurance)
imposed with respect to non-mail-order coverage
is not greater (as a percentage of charges or
dollar amount, as specified under the coverage)
than the cost-sharing imposed with respect to
the mail-order coverage.
``(3) Definitions.--For purposes of this subsection:
``(A) Mail-order prescription drug coverage.--The
term `mail-order prescription drug coverage' means
provision of benefits for prescription drugs and
biologicals that are delivered directly to participants
and beneficiaries through the mail or similar means.
``(B) Non-mail-order prescription drug coverage.--
The term `non-mail-order prescription drug coverage'
means the provision of benefits for prescription drugs
and biologicals through one or more local pharmacies.
``(C) Local pharmacy.--The term `local pharmacy'
means, with respect to a prescription drug or
biological and a participant or beneficiary, an
establishment that is authorized to dispense such drug
or biological and that is located within such distance
(not to exceed 5 miles in the case of a participant or
beneficiary residing in an urban area or 10 miles in
the case of a participant or beneficiary residing in a
non-urban area) of the residence of such participant or
beneficiary, as the Secretary of Health and Human
Services shall prescribe.
``(b) Prohibitions.--A group health plan, and a health insurance
issuer offering group health insurance coverage in connection with a
group health plan, may not provide monetary payments or rebates to an
individual to encourage such individual to accept less than the minimum
protections available under this section.
``(c) 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 coverage, 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).
``(d) Notice.--A group health plan under this part shall comply
with the notice requirement under section 714(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 2707''.
(2) ERISA amendments.--(A) 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. 714. EQUITY IN PROVISION OF PRESCRIPTION DRUG COVERAGE.
``(a) Equity in Provision of Prescription Drug Coverage.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage, that
provides for mail-order prescription drug coverage (as defined
in paragraph (3)(A)) shall also provide non-mail-order
prescription drug coverage consistent with paragraph (2).
``(2) Equitable coverage.--A plan or coverage provides non-
mail-order prescription drug coverage consistent with this
paragraph only if--
``(A) benefits under the non-mail-order
prescription coverage are provided for in the case of
all drugs and all circumstances under which benefits
are provided under the mail-order prescription drug
coverage;
``(B) no deductible or similar cost-sharing is
imposed with respect to benefits under the non-mail-
order prescription drug coverage unless such a
deductible or similar cost-sharing is imposed with
respect to benefits under the mail-order prescription
drug coverage; and
``(C) the benefits for the non-mail-order coverage
assures payments consistent with either (or both) of
the following clauses:
``(i) The dollar amount of payment for
prescription drug coverage is not less than the
dollar amount of benefits provided with respect
to the mail-order coverage for that same
coverage.
``(ii) The cost-sharing (including
deductibles, copayments, or coinsurance)
imposed with respect to non-mail-order coverage
is not greater (as a percentage of charges or
dollar amount, as specified under the coverage)
than the cost-sharing imposed with respect to
the mail-order coverage.
``(3) Definitions.--For purposes of this subsection:
``(A) Mail-order prescription drug coverage.--The
term `mail-order prescription drug coverage' means
provision of benefits for prescription drugs and
biologicals that are delivered directly to participants
and beneficiaries through the mail or similar means.
``(B) Non-mail-order prescription drug coverage.--
The term `non-mail-order prescription drug coverage'
means the provision of benefits for prescription drugs
and biologicals through one or more local pharmacies.
``(C) Local pharmacy.--The term `local pharmacy'
means, with respect to a prescription drug or
biological and a participant or beneficiary, an
establishment that is authorized to dispense such drug
or biological and that is located within such distance
(not to exceed 5 miles in the case of a participant or
beneficiary residing in an urban area or 10 miles in
the case of a participant or beneficiary residing in a
non-urban area) of the residence of such participant or
beneficiary, as the Secretary of Health and Human
Services shall prescribe.
``(b) Prohibitions.--A group health plan, and a health insurance
issuer offering group health insurance coverage in connection with a
group health plan, may not provide monetary payments or rebates to an
individual to encourage such individual to accept less than the minimum
protections available under this section.
``(c) 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 coverage, 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).
``(d) 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 714''.
(C) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is
amended by striking ``section 711'' and inserting ``sections
711 and 714''.
(D) The table of contents in section 1 of such Act is
amended by inserting after the item relating to section 713 the
following new item:
``Sec. 714. Equity in provision of prescription drug coverage.''.
(3) Internal revenue code amendments.--Subchapter B of
chapter 100 of the Internal Revenue Code of 1986 is amended--
(A) in the table of sections, by inserting after
the item relating to section 9812 the following new
item:
``Sec. 9813. Equity in provision of
prescription drug coverage.'';
and
(B) by inserting after section 9812 the following:
``SEC. 9813. EQUITY IN PROVISION OF PRESCRIPTION DRUG COVERAGE.
``(a) Equity in Provision of Prescription Drug Coverage.--
``(1) In general.--A group health plan that provides for
mail-order prescription drug coverage (as defined in paragraph
(3)(A)) shall also provide non-mail-order prescription drug
coverage consistent with paragraph (2).
``(2) Equitable coverage.--A plan provides non-mail-order
prescription drug coverage consistent with this paragraph only
if--
``(A) benefits under the non-mail-order
prescription coverage are provided for in the case of
all drugs and all circumstances under which benefits
are provided under the mail-order prescription drug
coverage;
``(B) no deductible or similar cost-sharing is
imposed with respect to benefits under the non-mail-
order prescription drug coverage unless such a
deductible or similar cost-sharing is imposed with
respect to benefits under the mail-order prescription
drug coverage; and
``(C) the benefits for the non-mail-order coverage
assures payments consistent with either (or both) of
the following clauses:
``(i) The dollar amount of payment for
prescription drug coverage is not less than the
dollar amount of benefits provided with respect
to the mail-order coverage for that same
coverage.
``(ii) The cost-sharing (including
deductibles, copayments, or coinsurance)
imposed with respect to non-mail-order coverage
is not greater (as a percentage of charges or
dollar amount, as specified under the coverage)
than the cost-sharing imposed with respect to
the mail-order coverage.
``(3) Definitions.--For purposes of this subsection:
``(A) Mail-order prescription drug coverage.--The
term `mail-order prescription drug coverage' means
provision of benefits for prescription drugs and
biologicals that are delivered directly to participants
and beneficiaries through the mail or similar means.
``(B) Non-mail-order prescription drug coverage.--
The term `non-mail-order prescription drug coverage'
means the provision of benefits for prescription drugs
and biologicals through one or more local pharmacies.
``(C) Local pharmacy.--The term `local pharmacy'
means, with respect to a prescription drug or
biological and a participant or beneficiary, an
establishment that is authorized to dispense such drug
or biological and that is located within such distance
(not to exceed 5 miles in the case of a participant or
beneficiary residing in an urban area or 10 miles in
the case of a participant or beneficiary residing in a
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