Section 1 Short title
This Act may be cited as the “Prior Authorization Reform for Autoimmune and Blood Disorders Act”.
Prior Authorization Reform for Autoimmune and Blood Disorders Act
A BILL
To amend the Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and the Internal Revenue Code of 1986 to require health insurance coverage of drugs indicated for the treatment of autoimmune diseases and certain blood disorders.
Sec. 2 Requiring coverage of drugs indicated for the treatment of autoimmune diseases and certain blood disorders
ERISA amendments—
In general— Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section:
“727. Requirements with respect to coverage of drugs for autoimmune diseases and certain blood disorders
“(a) In general—A group health plan, and a health insurance issuer offering group health insurance coverage—
“(1) shall provide coverage for any drug that is an autoimmune or blood disorder drug, without regard to whether such drug is dispensed by a pharmacy or furnished incident to another item or service for which benefits are available under such plan or coverage; and
“(2) may not require, with respect to an individual enrolled under such plan or coverage, that prior authorization for such a drug be obtained more than once during any 12-month period unless such drug is—
“(A) typically used for a period of 12 months or less;
“(B) an opioid, a benzodiazepine, a barbiturate, or carisoprodol; or
“(C) a drug with respect to which a risk evaluation and mitigation strategy is required under Section 505–1 of the Federal Food, Drug, and Cosmetic Act.
“(b) Autoimmune or blood disorder drug defined—In this section, the term autoimmune or blood disorder drug means a drug or biological product that is indicated and prescribed for the treatment of an autoimmune disease, hemophilia, or Von Willebrand disease.”
Clerical amendment— The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.) is amended by inserting after the item relating to section 726 the following:
Public Health Service Act amendments— Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–111 et seq.) is amended by adding at the end the following new section:
“2799A–12. Requirements with respect to coverage of drugs for autoimmune diseases and certain blood disorders
“(a) In general—A group health plan, and a health insurance issuer offering group or individual health insurance coverage—
“(1) shall provide coverage for any drug that is an autoimmune or blood disorder drug, without regard to whether such drug is dispensed by a pharmacy or furnished incident to another item or service for which benefits are available under such plan or coverage; and
“(2) may not require, with respect to an individual enrolled under such plan or coverage, that prior authorization for such a drug be obtained more than once during any 12-month period unless such drug is—
“(A) typically used for a period of 12 months or less;
“(B) an opioid, a benzodiazepine, a barbiturate, or carisoprodol; or
“(C) a drug with respect to which a risk evaluation and mitigation strategy is required under Section 505–1 of the Federal Food, Drug, and Cosmetic Act.
“(b) Autoimmune or blood disorder drug defined—In this section, the term autoimmune or blood disorder drug means a drug or biological product that is indicated and prescribed for the treatment of an autoimmune disease, hemophilia, or Von Willebrand disease.”
Internal Revenue Code amendments—
In general— Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:
“9827. Requirements with respect to coverage of drugs for autoimmune diseases and certain blood disorders
“(a) In general—A group health plan—
“(1) shall provide coverage for any drug that is an autoimmune or blood disorder drug, without regard to whether such drug is dispensed by a pharmacy or furnished incident to another item or service for which benefits are available under such plan; and
“(2) may not require, with respect to an individual enrolled under such plan, that prior authorization for such a drug be obtained more than once during any 12-month period unless such drug is—
“(A) typically used for a period of 12 months or less;
“(B) an opioid, a benzodiazepine, a barbiturate, or carisoprodol; or
“(C) a drug with respect to which a risk evaluation and mitigation strategy is required under Section 505–1 of the Federal Food, Drug, and Cosmetic Act.
“(b) Autoimmune or blood disorder drug defined—In this section, the term autoimmune or blood disorder drug means a drug or biological product that is indicated and prescribed for the treatment of an autoimmune disease, hemophilia, or Von Willebrand disease.”
Clerical amendment— The table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item:
Effective date— The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2027.