Limitations on cost-sharing for opioid overdose reversal medications

(a) Limitations on cost-Sharing (1) Public Health Service Act 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: 2799A–12. Limitations on cost-sharing for opioid overdose reversal agents (a) In general A group health plan or a health insurance issuer offering group or individual health insurance coverage shall provide coverage for, and shall not impose any cost-sharing requirement under the plan or coverage with respect to at least one formulation of an opioid overdose reversal agent. (b) Utilization control policies; medical management A group health plan or health insurance issuer offering group or individual health insurance coverage shall not impose any utilization control policies or procedures (as defined by the Secretary), including prior authorization requirements, with respect to opioid overdose reversal agents covered under the plan or coverage. Such a plan or issuer may apply medical management practices in providing the benefits described in subsection (a). (c) Definition In this section, the term opioid overdose reversal agent means a drug or biological product approved by the Food and Drug Administration for one of the following uses (or a similar use): (1) Complete or partial reversal of opioid depression, including respiratory depression, induced by opioids. (2) Emergency treatment of a known or suspected opioid overdose, as manifested by respiratory or central nervous system depression.. (2) Employee Retirement Income Security Act of 1974 (A) 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 amend by adding at the end the following: 727. Limitations on cost-sharing for opioid overdose reversal agents (a) In general A group health plan or a health insurance issuer offering group health insurance coverage shall provide coverage for, and shall not impose any cost-sharing requirement under the plan or coverage with respect to at least one formulation of an opioid overdose reversal agent. (b) Utilization control policies; medical management A group health plan or health insurance issuer offering group health insurance coverage shall not impose any utilization control policies or procedures (as defined by the Secretary), including prior authorization requirements, with respect to opioid overdose reversal agents covered under the plan or coverage. Such a plan or issuer may apply medical management practices in providing the benefits described in subsection (a). (c) Definition In this section, the term opioid overdose reversal agent means a drug or biological product approved by the Food and Drug Administration for one of the following uses (or a similar use): (1) Complete or partial reversal of opioid depression, including respiratory depression, induced by opioids. (2) Emergency treatment of a known or suspected opioid overdose, as manifested by respiratory or central nervous system depression.. (B) 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 new item: Sec. 727. Limitations on cost-sharing for opioid overdose reversal agents.. (3) Internal Revenue Code of 1986 (A) In general Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following: 9827. Limitations on cost-sharing for opioid overdose reversal agents (a) In general A group health plan shall provide coverage for, and shall not impose any cost-sharing requirement under the plan with respect to at least one formulation of an opioid overdose reversal agent. (b) Utilization control policies; medical management A group health plan shall not impose any utilization control policies or procedures (as defined by the Secretary), including prior authorization requirements, with respect to opioid overdose reversal agents covered under the plan. Such a plan may apply medical management practices in providing the benefits described in subsection (a). (c) Definition In this section, the term opioid overdose reversal agent means a drug or biological product approved by the Food and Drug Administration for one of the following uses (or a similar use): (1) Complete or partial reversal of opioid depression, including respiratory depression, induced by opioids. (2) Emergency treatment of a known or suspected opioid overdose, as manifested by respiratory or central nervous system depression.. (B) 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: Sec. 9827. Limitations on cost-sharing for opioid overdose reversal agents.. (4) Effective date The amendments made by this subsection shall apply to plan years beginning on or after January 1, 2027. (b) Safe harbor for absence of deductible for opioid overdose reversal agents (1) In general Paragraph (2) of section 223(c) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: (I) Safe harbor for absence of deductible for opioid overdose reversal agents A plan shall not fail to be treated as a high deductible health plan by reason of failing to have a deductible for opioid overdose reversal agents (as defined in section 9827(c)).. (2) Effective date The amendment made by this section shall apply to plan years beginning on or after January 1, 2027. (c) Limitations on cost-Sharing under Medicare part D (1) In general Section 1860D–2 of the Social Security Act (42 U.S.C. 1395w–102) is amended— (A) in subsection (b)— (i) in paragraph (1)(A), in the matter preceding clause (i), by striking and (9) and inserting, (9), and (10); (ii) in paragraph (2)(A), in the matter preceding clause (i), by striking and (9) and inserting, (9), and (10); and (iii) by adding at the end the following new paragraph: (10) Limitations on cost-sharing for opioid overdose reversal agents (A) In general For plan year 2027 and each subsequent plan year, each prescription drug plan and MA–PD plan shall not impose any cost-sharing requirement under the plan with respect to at least one brand or generic version of an opioid overdose reversal agent (as defined in section 2799A–11 of the Public Health Service Act). The requirement under the preceding sentence shall also apply to cost-sharing applicable to subsidy eligible individuals under section 1814D–14. (B) Cost-sharing For purposes of subparagraph (A), the elimination of cost-sharing shall include the following: (i) No application of deductible The waiver of the deductible under paragraph (1). (ii) No application of coinsurance The waiver of coinsurance under paragraph (2).; and (B) in subsection (c), by adding at the end the following new paragraph: (7) Treatment of cost-sharing for opioid overdose reversal agents The coverage is provided in accordance with subsection (b)(10).. (2) Conforming amendments to cost-sharing for low-income individuals Section 1860D–14(a)(1) of the Social Security Act (42 U.S.C. 1395w–114(a)(1)) is amended, in the matter preceding subparagraph (A), by striking In the case and inserting Subject to section 1860D–2(b)(10), in the case.