SSB 3161 (LSB 6094XC (3) 88)

SENATE FILE _____ 

BY  (PROPOSED COMMITTEE ON HUMAN RESOURCES BILL BY CHAIRPERSON SWEENEY)

A BILL FOR

An Act relating to insurance coverage for prescription drugs used in the treatment of stage IV cancer, and including applicability provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.24A  Prescription drugs —— stage IV cancer.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Associated conditions” means symptoms or side effects associated with stage IV cancer, or with the health care services for stage IV cancer provided by a covered person’s health care professional, that in the opinion of the health care professional further jeopardize the covered person’s health if left untreated. 
   b.  “Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses that provides coverage for prescription drugs.
   c.  “Health care professional” means the same as defined in section 514J.102.
   d.  “Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. 
   e.  “Prescription cancer drug” means a prescription drug that is used for the treatment of stage IV cancer. 
   f.  “Prescription drug” means a prescription drug that has been prescribed as medically necessary by a covered person’s health care professional. 
   g.  “Stage IV cancer” means cancer that has spread from the primary or original site of the cancer to other parts of the body. Stage IV cancer may also be referred to as advanced cancer or metastatic cancer.
   h.  “Step therapy protocol” means the same as defined in section 514F.7.
   2.  a.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses that provides coverage for prescription drugs shall provide coverage for prescription cancer drugs. 
   b.  Notwithstanding section 514F.7, the policy, contract, or plan shall provide coverage, without imposing a step therapy protocol, for a prescription cancer drug that meets all of the following requirements:
   (1)  The use of the prescription cancer drug is in accordance with the medical standards of care for stage IV cancer.
   (2)  The use of the prescription cancer drug for stage IV cancer is supported by peer-reviewed, evidence-based literature.
   (3)  The prescription cancer drug has been approved by the United States food and drug administration.
   3.  a.  This section shall apply to the following classes of third-party payment provider contracts, policies, or plans:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  A plan established for public employees pursuant to chapter 509A.
   b.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
   4.  The commissioner of insurance shall adopt rules pursuant to chapter 17A to administer this section.
    Sec. 2.  APPLICABILITY.  This Act applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2021.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to insurance coverage for prescription drugs used in the treatment of stage IV cancer.
   The bill requires policies, contracts, or plans providing for third-party payment or prepayment of health or medical expenses that provide coverage for prescription drugs to provide coverage for prescription cancer drugs. “Prescription cancer drug” is defined in the bill as a prescription drug that is used to treat stage IV cancer. “Stage IV cancer” is also defined in the bill.
    The policy, contract, or plan is required to provide coverage, without imposing a step therapy protocol, for a prescription cancer drug that has been approved by the United States food and drug administration, the use of which is in accordance with medical standards of care for stage IV cancer, and the use of which is supported by peer-reviewed, evidence-based literature. “Step therapy protocol” is defined in the bill as a protocol or program that establishes a specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular covered person are covered under a pharmacy or medical benefit by a health carrier, a health benefit plan, or a utilization review organization, including self-administered drugs and drugs administered by a health care professional.
   The bill applies to the third-party payment providers enumerated in the bill. The bill specifies the types of specialized health-related insurance which are not subject to the coverage requirements of the bill.
   The commissioner of insurance is required to adopt rules to administer the requirements of the bill.
   The provisions of the bill are applicable to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2021.