Delaware program
Check a high charge for oral cancer medicine
Delaware-regulated plans have rules limiting your share of the cost for covered oral anticancer medicines.
What it is
Delaware-regulated plans have rules limiting your share of the cost for covered oral anticancer medicines.
A covered chemo pill costs you the lower of the plan's pharmacy charge or its infused-treatment charge. Money a charity or drug company pays on your behalf also counts toward your deductible. The $150 specialty-drug cap is a separate rule for individual policies only.
Eligibility rules
- The oral anticancer rule covers qualifying Delaware individual, group and blanket policies that cover prescription and anticancer medicines.
- The applicable policy must have been delivered, issued, renewed, modified or amended on or after January 1, 2013. Self-funded employer coverage has different rules.
What you get
- The lower of the plan’s pill or infusion cost-sharing amounts for a covered oral chemotherapy drug.
- A $150 copay or coinsurance cap per 30-day specialty supply on an eligible individual policy.
- Qualifying drug assistance counts toward your deductible and out-of-pocket limit; health savings account rules can limit this.
What the help includes
- The parity rule controls cost sharing. It does not require a plan to cover every anticancer drug.
- The assistance-counting law applies to plans entered, amended, extended or renewed on or after January 1, 2024. This protection is separate from the oral-anticancer parity rule and the $150 individual-policy specialty copay or coinsurance cap. That cap is not a deductible cap.
If you decide to apply
- Ask the oncology pharmacist which benefit is paying for the medicine.
- Ask the plan for a written comparison of the pill and infusion charges. Have both cost schedules ready.
Health plan; Department of Insurance Consumer Services · 302-674-7310 · Official page ↗
What happens next
- The plan’s written comparison identifies which cost-sharing amount applies to the pharmacy bill.
Good to know
The $150 cap is in the individual-policy law. It is not a general cap for employer plans.
Other details
- Qualifying drug assistance generally counts toward cost sharing, including the deductible and out-of-pocket limit. For an HSA-qualified plan, the exception applies only as needed to preserve federal HSA eligibility before the minimum deductible is met; preventive care has different treatment.
Official sources
- 18 Del. C. ch. 33, subch. I — Individual health insurance mandates
- 18 Del. C. ch. 35, subch. III — Group and blanket health insurance mandates
- 83 Del. Laws ch. 522 — Cost-sharing contributions (enactment)
- 18 Del. C. ch. 33, subch. II, prior authorization
- 85 Del. Laws ch. 176, approved August 25, 2025; implementation §4
- 18 Del. C. §§6416–6417, Independent Health Appeals Program
- 18 DE Admin. Code 1301, especially §§4–6; April 2023 revision
- Delaware Insurance Department, Independent Health Care Appeals Program
“Are the pill-versus-infusion rule or assistance-counting rules relevant to this medicine? What could they save, what are their limits, and could you help request a billing review?”
Why I’m asking: I want to understand the pharmacy charge and whether assistance counts toward our deductible.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask for the comparison in writing before paying a large pharmacy bill.
Your social worker
The oncology pharmacist can say which benefit the drug is being billed under.
The care team
Records and letters when the application asks for them.
- Who decides
- The plan.
- Ask your social worker
- “Is this chemotherapy being billed under the pharmacy benefit? Delaware makes the plan charge the lower of the pill and drip amounts on an insured plan.”
How to apply
First step: Ask the plan in writing what the same drug would cost infused, and to apply the lower amount.
- Ask the plan in writing what the same drug would cost if it were infused, and to apply the lower amount.
- Ask the specialty pharmacy whether any assistance is being counted towards the deductible.
Official application / program page ↗
Where it starts: Ask the plan in writing to compare the oral and infused cost sharing and apply the lower.
What to gather
- The drug name and the pharmacy charge
- The plan’s pharmacy and medical cost-sharing schedules
How long: As long as the plan takes to answer a written question; ask for a date.
What a yes looks like
The pharmacy charge drops to the medical-benefit amount.
What a no looks like, and the next move
If the plan says it is self-funded, the state rule does not reach it. Ask the benefits office to confirm in writing.
Watch out
- It governs the price, not whether the drug is covered at all.
- The $150 specialty cap sits in the individual-policy chapter, which excludes group policies. Do not quote it at an employer plan.
- An HSA-qualified plan can limit assistance counting only as necessary to preserve federal HSA eligibility before the minimum deductible; preventive care differs.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
The lower of the two chemo cost-sharing amounts, money paid on your behalf counted, and a $150 monthly specialty cap on an individual Delaware policy.
- $150/month — Specialty-tier copay or coinsurance cap on an individual Delaware policy
- $30 — Supply length the cap is measured against
Legal protection: An oral anticancer drug carries the lower of the plan’s prescription cost sharing or its cost sharing for an infused or injected anticancer drug · Cost-sharing amounts paid by the enrollee or on the enrollee’s behalf must be counted towards the plan’s cost-sharing requirement · Routine patient care costs in a qualifying clinical trial for a life-threatening disease are covered
What it costs the family: None to invoke.
The eligibility facts, as published
- Plan type
- individual, group or blanket policies delivered, issued, renewed, modified or amended in Delaware on or after January 1, 2013 that cover prescription drugs and anticancer medication; the specialty-tier cap is in the individual chapter only
- Limitation
- the parity law does not itself require any particular anticancer drug to be covered
- Hsa
- The HSA exception applies only as necessary to preserve federal HSA eligibility before the minimum deductible; preventive care has different treatment.
The trap: The parity law does not force a plan to cover a particular drug. It governs what the plan charges once it does cover it.
Where I read this
- 18 Del. C. ch. 33, subch. I — Individual health insurance mandates — Delaware General Assembly, read September 10, 2026
- 18 Del. C. ch. 35, subch. III — Group and blanket health insurance mandates — Delaware General Assembly, read September 10, 2026
- 83 Del. Laws ch. 522 — Cost-sharing contributions (enactment) — Delaware General Assembly, read September 10, 2026