Health plans would let patients choose pharmacies for cancer medicines

Insurers and health plans would be barred from requiring or rewarding certain delivery routes for cancer and blood disease medicines. This applies to insurers, health maintenance organizations and their pharmacy benefits managers, and covers medicines prescribed for patients with cancer or blood diseases. The rule covers supportive medicines for side effects, even when a medicine does not directly treat cancer or a blood disease. Payment must follow the provider agreement rate, or wholesale acquisition cost if the agreement has no rate. This provision applies only to agreements entered into on or after July 1, 2026.

Plans and pharmacy benefit managers would have to let covered people choose a pharmacy, including certain out-of-network pharmacies that accept plan rates. The rule applies to people whose insurance includes pharmacy benefits, including specialty medicines, under covered insurer, corporation or health maintenance organization plans. An out-of-network pharmacy must agree to accept the rates and copayments applicable to network pharmacies as payment in full. The plan may require the pharmacy to sign the same kind of service or network agreement required of network pharmacies; a pharmacy that does not sign is not covered by this rule until it does. The choice rule does not apply to certain mail-order contracts or employer self-funded plans, and a health maintenance organization may exclude benefits from its wholly owned or operated pharmacy.

Plans and pharmacy benefit managers would be barred from using unequal fees or financial penalties to steer a person's pharmacy choice. The rule applies to people receiving pharmacy benefits under covered plans and to non-network pharmacies that qualify under the agreement rules. This does not prevent an insurer from choosing one mail-order pharmacy for drugs delivered by mail, or an employer self-funded plan from encouraging use of onsite or mail-delivery pharmacies. A pharmacy must meet applicable agreement requirements to receive the protections described here.