District of Columbia program
Fair coverage terms for oral cancer medicines
DC law limits how a covered plan charges for chemotherapy pills compared with intravenous treatment.
What it is
DC law limits how a covered plan charges for chemotherapy pills compared with intravenous treatment.
Moving treatment to tablets changes how the plan bills the prescription. On a plan DC regulates, the pill's cost share cannot be worse than the same treatment by drip. A plan where the employer pays its own claims follows federal rules instead, and HR can say which yours is.
Eligibility rules
- An individual or group plan with prescription drug cover that is subject to the District insurance regulator.
- Treated under a District-regulated plan.
What you get
- Coverage terms for prescribed oral cancer medicine no less favorable than IV or injected cancer treatment, on a qualifying plan.
Other protections
- The comparison also reaches annual maximums. You may use any appropriately licensed pharmacy.
- The group-plan rule applies for plan years beginning from 2009. Private employer self-funded plans follow federal rules instead.
If you decide to apply
- Ask the pharmacy for the written charge and the oncology team about the intravenous comparison.
- Ask your plan to review the charge under DC's oral anticancer medication law.
The plan, under District law · Official page ↗
Good to know
This protection compares coverage terms. It does not require the pill to have an IV version or promise identical bills.
Official sources
- D.C. Code § 31-2995.02 — Orally administered anticancer medication coverage
- D.C. Code § 31-2995.03 — Applicability
- D.C. Code § 31-2995.01 — Oral chemotherapy definitions
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
“One of our child's cancer medicines is a pill and the charge looks high. Could you help us find out whether the plan is allowed to charge more for it than for chemotherapy in the clinic, and ask for a correction if not?”
Why I’m asking: I want to understand whether our plan is charging correctly and what we would still owe.
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
Get the quote in writing and challenge it with the rule named.
Your social worker
The pharmacy gives the quote; the oncology team confirms what the intravenous version would have been.
The care team
Records and letters when the application asks for them.
- Who decides
- The plan, under District law.
- Ask the agency
- “District law requires cost sharing for orally administered anticancer medication to be no less favourable than for the intravenous version. Please recalculate this charge.”
How to apply
First step: Get the pharmacy quote in writing, then write to the plan naming the parity rule.
- Get the quoted amount in writing from the pharmacy.
- Write to the plan naming the parity rule and ask for a recalculation.
- If they refuse, use the external appeal.
Official application / program page ↗
Where it starts: Tell the plan in writing that District law requires parity with the intravenous version, and ask for the charge to be recalculated.
What to gather
The diagnosis letter, the child’s insurance card, and the last two pay stubs cover most applications. The official page lists the rest.
How long: No decision clock is published for this; use the appeal clocks if refused.
What a yes looks like
A recalculated charge in line with the intravenous benefit.
What a no looks like, and the next move
Appeal inside the plan, then ask the District for an outside review.
Watch out
- It is a comparison, not a dollar cap.
- Private employer self-funded plans follow federal rules instead.
If they say no, quote this: D.C. Code § 31-2995.02(b): coverage "on a basis no less favorable than coverage provided for intravenously administered or injected cancer medications".
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
Coverage terms for prescribed oral cancer medicines no less favorable than IV or injected cancer medicines on a qualifying DC-regulated plan.
- $2,009 — Plan years from which the rule applies to group plans
Legal protection: Deductibles, coinsurance, copayments and annual maximums for tablets must be no less favourable than for the drip · You can use any appropriately licensed pharmacy
What it costs the family: Nothing to invoke.
The eligibility facts, as published
- Other
- An individual or group plan with prescription drug cover that is subject to the District insurance regulator
- Residency
- Treated under a District-regulated plan
The trap: It is parity, not a dollar cap. There is no published limit per prescription, only the rule that it cannot be worse than the drip.
Where I read this
- D.C. Code § 31-2995.02 — Orally administered anticancer medication coverage — Council of the District of Columbia, read September 10, 2026
- D.C. Code § 31-2995.03 — Applicability — Council of the District of Columbia, read September 10, 2026
- D.C. Code § 31-2995.01 — Oral chemotherapy definitions — Council of the District of Columbia, read September 10, 2026