Senate Study Bill 3161 - Introduced SENATE FILE _____ BY (PROPOSED COMMITTEE ON HUMAN RESOURCES BILL BY CHAIRPERSON SWEENEY) A BILL FOR An Act relating to insurance coverage for prescription drugs 1 used in the treatment of stage IV cancer, and including 2 applicability provisions. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 6094XC (3) 88 ko/rn

S.F. _____ Section 1. NEW SECTION . 514C.24A Prescription drugs —— 1 stage IV cancer. 2 1. As used in this section, unless the context otherwise 3 requires: 4 a. “Associated conditions” means symptoms or side effects 5 associated with stage IV cancer, or with the health care 6 services for stage IV cancer provided by a covered person’s 7 health care professional, that in the opinion of the health 8 care professional further jeopardize the covered person’s 9 health if left untreated. 10 b. “Covered person” means a policyholder, subscriber, or 11 other person participating in a policy, contract, or plan that 12 provides for third-party payment or prepayment of health or 13 medical expenses that provides coverage for prescription drugs. 14 c. “Health care professional” means the same as defined in 15 section 514J.102. 16 d. “Health care services” means services for the diagnosis, 17 prevention, treatment, cure, or relief of a health condition, 18 illness, injury, or disease. 19 e. “Prescription cancer drug” means a prescription drug that 20 is used for the treatment of stage IV cancer. 21 f. “Prescription drug” means a prescription drug that has 22 been prescribed as medically necessary by a covered person’s 23 health care professional. 24 g. “Stage IV cancer” means cancer that has spread from the 25 primary or original site of the cancer to other parts of the 26 body. Stage IV cancer may also be referred to as advanced 27 cancer or metastatic cancer. 28 h. “Step therapy protocol” means the same as defined in 29 section 514F.7. 30 2. a. Notwithstanding the uniformity of treatment 31 requirements of section 514C.6, a policy, contract, or plan 32 providing for third-party payment or prepayment of health or 33 medical expenses that provides coverage for prescription drugs 34 shall provide coverage for prescription cancer drugs. 35 -1- LSB 6094XC (3) 88 ko/rn 1/ 4

S.F. _____ b. Notwithstanding section 514F.7, the policy, contract, or 1 plan shall provide coverage, without imposing a step therapy 2 protocol, for a prescription cancer drug that meets all of the 3 following requirements: 4 (1) The use of the prescription cancer drug is in accordance 5 with the medical standards of care for stage IV cancer. 6 (2) The use of the prescription cancer drug for stage 7 IV cancer is supported by peer-reviewed, evidence-based 8 literature. 9 (3) The prescription cancer drug has been approved by the 10 United States food and drug administration. 11 3. a. This section shall apply to the following classes of 12 third-party payment provider contracts, policies, or plans: 13 (1) Individual or group accident and sickness insurance 14 providing coverage on an expense-incurred basis. 15 (2) An individual or group hospital or medical service 16 contract issued pursuant to chapter 509, 514, or 514A. 17 (3) An individual or group health maintenance organization 18 contract regulated under chapter 514B. 19 (4) A plan established for public employees pursuant to 20 chapter 509A. 21 b. This section shall not apply to accident-only, specified 22 disease, short-term hospital or medical, hospital confinement 23 indemnity, credit, dental, vision, Medicare supplement, 24 long-term care, basic hospital and medical-surgical expense 25 coverage as defined by the commissioner of insurance, 26 disability income insurance coverage, coverage issued as a 27 supplement to liability insurance, workers’ compensation or 28 similar insurance, or automobile medical payment insurance. 29 4. The commissioner of insurance shall adopt rules pursuant 30 to chapter 17A to administer this section. 31 Sec. 2. APPLICABILITY. This Act applies to third-party 32 payment provider contracts, policies, or plans delivered, 33 issued for delivery, continued, or renewed in this state on or 34 after January 1, 2021. 35 -2- LSB 6094XC (3) 88 ko/rn 2/ 4

S.F. _____ EXPLANATION 1 The inclusion of this explanation does not constitute agreement with 2 the explanation’s substance by the members of the general assembly. 3 This bill relates to insurance coverage for prescription 4 drugs used in the treatment of stage IV cancer. 5 The bill requires policies, contracts, or plans providing 6 for third-party payment or prepayment of health or medical 7 expenses that provide coverage for prescription drugs to 8 provide coverage for prescription cancer drugs. “Prescription 9 cancer drug” is defined in the bill as a prescription drug that 10 is used to treat stage IV cancer. “Stage IV cancer” is also 11 defined in the bill. 12 The policy, contract, or plan is required to provide 13 coverage, without imposing a step therapy protocol, for a 14 prescription cancer drug that has been approved by the United 15 States food and drug administration, the use of which is 16 in accordance with medical standards of care for stage IV 17 cancer, and the use of which is supported by peer-reviewed, 18 evidence-based literature. “Step therapy protocol” is defined 19 in the bill as a protocol or program that establishes a 20 specific sequence in which prescription drugs for a specified 21 medical condition and medically appropriate for a particular 22 covered person are covered under a pharmacy or medical benefit 23 by a health carrier, a health benefit plan, or a utilization 24 review organization, including self-administered drugs and 25 drugs administered by a health care professional. 26 The bill applies to the third-party payment providers 27 enumerated in the bill. The bill specifies the types of 28 specialized health-related insurance which are not subject to 29 the coverage requirements of the bill. 30 The commissioner of insurance is required to adopt rules to 31 administer the requirements of the bill. 32 The provisions of the bill are applicable to third-party 33 payment provider contracts, policies, or plans delivered, 34 issued for delivery, continued, or renewed in this state on or 35 -3- LSB 6094XC (3) 88 ko/rn 3/ 4

S.F. _____ after January 1, 2021. 1 -4- LSB 6094XC (3) 88 ko/rn 4/ 4