Cancer Drug Parity

Summary#

This bill would change the Employee Retirement Income Security Act of 1974 to require certain group health plans (and the insurance they offer) to make cost-sharing for prescribed, patient‑administered oral anticancer medicines no less favorable than the cost-sharing for anticancer medicines given by a health care provider (for example, intravenous or injected drugs). The rule applies only to FDA‑approved anticancer drugs that a treating physician finds medically necessary or clinically appropriate. Plans may still use prior authorization and other utilization controls. Plans cannot respond by raising out‑of‑pocket costs, reclassifying benefits to increase costs, or applying stricter limits to oral anticancer drugs. The change would apply to plan years starting on or after January 1, 2027. The bill also directs the Government Accountability Office (GAO) to study the law’s impact within two years of enactment and report to Congress.

What it means for you#

• Who is covered: group health plans and health insurance coverage offered in connection with those plans, as defined under ERISA.
• What changes: if your plan covers anticancer drugs given by a provider, it must offer at least equally favorable cost‑sharing for prescribed oral anticancer drugs that are FDA approved and deemed necessary or appropriate by your treating physician.
• Cost‑sharing types covered: deductible, coinsurance, copayment, and maximum limits on those out‑of‑pocket costs.
• Protections: plans may not increase out‑of‑pocket costs or reclassify benefits to avoid the rule. State laws that give greater protections remain in effect.
• Limits: the bill does not require using oral drugs instead of other treatments, and plans may still require prior authorization and other utilization controls.
• Timing: the rule applies to plan years beginning on or after January 1, 2027.

Expenses#

No publicly available information. The bill does not include a federal cost estimate. The bill does require the GAO to study the impact on out‑of‑pocket costs and to report to Congress within two years after enactment.

Proponents' View#

The bill’s stated purpose is to ensure parity in how plans require cost‑sharing for oral anticancer drugs versus drugs given by a health care provider. Supporters present the change as a way to make cost‑sharing for patient‑administered oral anticancer medicines at least as favorable as for provider‑administered treatments and to prevent plan design changes that would raise patient costs.

Opponents' View#

No publicly available information.