Cancer Drug Parity Act of 2025
- Sponsor
- Rep. Grothman, Glenn [R-WI-6]
- Committees
- Education and Workforce Committee (primary)
- Last action
- Jun 24, 2025
Bottom line
The bill mandates equal out-of-pocket costs for oral and provider-administered anticancer drugs under ERISA-governed health plans, aiming to improve patient access and affordability.
What it actually does
This bill amends the Employee Retirement Income Security Act of 1974 (ERISA) to require group health plans to provide cost-sharing for prescribed oral anticancer drugs on terms no less favorable than for anticancer medications administered by a healthcare provider. It explicitly prohibits plans from increasing overall out-of-pocket costs or reclassifying benefits to circumvent this parity requirement. The bill also mandates a Government Accountability Office (GAO) study on the impact of this change.
Proponents argue
Supporters argue that this bill will significantly reduce the financial burden on cancer patients, ensuring that the choice between oral and intravenously administered treatments is based on medical necessity rather than cost. They contend it modernizes health insurance coverage to reflect advancements in cancer treatment, where oral therapies are increasingly common and effective, promoting equitable access to life-saving medications.
Opponents contend
Critics might argue that while the intent is laudable, mandating specific benefit designs could lead to increased premiums for all participants in group health plans or for employers sponsoring these plans. They may also suggest that such mandates do not address the underlying high cost of cancer drugs and could shift costs rather than truly reduce them, potentially limiting plan flexibility in managing overall healthcare expenses.
The bill is very concise and clearly written, making it highly accessible for a reader to understand its core provisions quickly.
Section 2(a), inserting new Section 726(a) into ERISA
Mandate for Oral Anticancer Drug Cost-Sharing Parity
This provision requires group health plans and associated health insurance coverage that provide benefits for provider-administered anticancer medications to offer cost-sharing for prescribed, patient-administered oral anticancer drugs on terms that are no less favorable. This means that deductibles, coinsurance, copayments, and out-of-pocket maximums for oral cancer drugs must be equivalent to those for intravenously administered or injected cancer drugs.
Supporters argue
Supporters argue that this provision ensures equitable access to necessary cancer treatments, recognizing that oral medications are often as effective as, or even preferred over, intravenous options but have historically faced higher patient cost burdens. It removes a significant financial barrier that could force patients to choose less optimal treatment pathways.
Critics contend
Critics contend that this mandate could lead to increased premiums for all plan participants or employers, as health plans absorb the additional costs. They suggest it may also incentivize the use of more expensive oral drugs when other, potentially more cost-effective, options might be available, without addressing the underlying high cost of cancer medications.
Tradeoffs
This provision balances the critical need to improve patient access and affordability for cancer treatments against the potential for increased overall healthcare costs and premiums for group health plans.
Section 2(a), inserting new Section 726(c) into ERISA
Prohibition on Cost-Shifting to Undermine Parity
This section explicitly prevents group health plans from circumventing the oral anticancer drug parity requirement. Plans are prohibited from increasing out-of-pocket costs for anticancer medications generally, reclassifying benefits in a way that increases such costs, or applying more restrictive limitations on prescribed oral anticancer medications than on intravenously administered or injected ones. This aims to ensure that the parity mandate results in genuine patient benefit rather than superficial compliance that raises overall patient financial burden.
Section 3
Government Accountability Office Study on Impact
This section directs the Comptroller General of the United States (GAO) to conduct a study within two years of the Act's enactment. The study will assess the impact of the new parity requirement on the out-of-pocket costs for oral and patient-administered anticancer medications for individuals enrolled in ERISA-governed group health plans. It also requires a comparison to individuals in plans not subject to the rule and mandates recommendations for reducing financial barriers to these medications.
This clause clarifies that the federal parity requirement does not supersede any State law that provides greater protections regarding coverage for orally administered anticancer medications. This means states are free to enact or maintain laws that offer more favorable terms for patients than the federal standard.
Section 2(a), inserting new Section 726(d)(3) into ERISA
Why it matters:This is standard legislative practice to clarify the relationship between federal and state law, particularly in areas of concurrent jurisdiction like health insurance regulation. It ensures that the federal floor for protections does not inadvertently preempt more robust state-level consumer safeguards.
Case for: Supporters argue this provision is crucial for preserving states' rights to innovate and provide stronger consumer protections, ensuring that the federal standard acts as a minimum floor rather than a ceiling for patient benefits. It allows states with existing strong parity laws to maintain them.
Case against: Critics might argue that allowing a patchwork of state laws, even if more protective, can create administrative complexity for multi-state employers and health plans. This could potentially increase compliance costs for insurers and employers operating across different jurisdictions.
Estimated impact: Ensures that cancer patients in states with existing or future stronger parity laws will continue to benefit from those enhanced protections, potentially affecting a significant number of individuals depending on state legislative activity and existing regulations.