Protecting Patient Access to Cancer and Complex Therapies Act

This bill changes how Medicare handles certain high-cost drugs that receive a negotiated “maximum fair price.” It keeps doctor and hospital payments the same as today, but makes drug companies pay Medicare a rebate to cover the difference when a negotiated price is lower. Your 20% coinsurance for these drugs would be based on the lower negotiated price, which can mean you pay less out of pocket. Rebates go to the Medicare trust fund, and there are penalties if a manufacturer does not comply. The bill also clarifies that companies don’t have to sell the drug at the negotiated price directly; they meet the requirement by paying the rebate instead .

Key points

• Who is affected: People on Medicare Part B who receive certain drugs, the clinics and hospitals that give them, and the drug manufacturers of those selected drugs .
• What changes:
  • Patients’ coinsurance is calculated from the lower negotiated price, potentially reducing out-of-pocket costs.
  • Medicare keeps paying providers under the current formula; manufacturers pay rebates to make up the difference, and those funds go to the Medicare trust fund .
  • Outpatient hospital and surgery center billing is aligned to follow the same coinsurance rule for these drugs .
  • These rebates aren’t counted when setting the pricing formula for provider payments, and reporting is coordinated with Medicaid rules .
• When: Applies by quarter after Medicare sets a negotiated price for a selected drug; manufacturers must pay rebates shortly after receiving usage and pricing info from the government .