House File 873 - Introduced HOUSE FILE 873 BY GAINES and THEDE 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 1639YH (2) 89 ko/rn

H.F. 873 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. 8 b. “Covered person” means a policyholder, subscriber, or 9 other person participating in a policy, contract, or plan that 10 provides for third-party payment or prepayment of health or 11 medical expenses that provides coverage for prescription drugs. 12 c. “Health care professional” means the same as defined in 13 section 514J.102. 14 d. “Health care services” means services for the diagnosis, 15 prevention, treatment, cure, or relief of a health condition, 16 illness, injury, or disease. 17 e. “Prescription cancer drug” means a prescription drug that 18 is used for the treatment of stage IV cancer. 19 f. “Prescription drug” means a prescription drug that has 20 been prescribed as medically necessary by a covered person’s 21 health care professional. 22 g. “Stage IV cancer” means cancer that has spread from the 23 primary or original site of the cancer to other parts of the 24 body. Stage IV cancer may also be referred to as advanced 25 cancer or metastatic cancer. 26 h. “Step therapy protocol” means the same as defined in 27 section 514F.7. 28 2. a. Notwithstanding the uniformity of treatment 29 requirements of section 514C.6, a policy, contract, or plan 30 providing for third-party payment or prepayment of health or 31 medical expenses that provides coverage for prescription drugs 32 shall provide coverage for prescription cancer drugs. 33 b. Notwithstanding section 514F.7, the policy, contract, or 34 plan shall provide coverage, without imposing a step therapy 35 -1- LSB 1639YH (2) 89 ko/rn 1/ 4

H.F. 873 protocol, for a prescription cancer drug that meets all of the 1 following requirements: 2 (1) The use of the prescription cancer drug is in accordance 3 with the medical standards of care for stage IV cancer. 4 (2) The use of the prescription cancer drug for stage 5 IV cancer is supported by peer-reviewed, evidence-based 6 literature. 7 (3) The prescription cancer drug has been approved by the 8 United States food and drug administration. 9 c. The policy, contract, or plan shall provide coverage, 10 and may impose a step therapy protocol, for a prescription drug 11 that is used to treat associated conditions. 12 3. a. This section shall apply to the following classes of 13 third-party payment provider contracts, policies, or plans: 14 (1) Individual or group accident and sickness insurance 15 providing coverage on an expense-incurred basis. 16 (2) An individual or group hospital or medical service 17 contract issued pursuant to chapter 509, 514, or 514A. 18 (3) An individual or group health maintenance organization 19 contract regulated under chapter 514B. 20 (4) A plan established for public employees pursuant to 21 chapter 509A. 22 b. This section shall not apply to accident-only, specified 23 disease, short-term hospital or medical, hospital confinement 24 indemnity, credit, dental, vision, Medicare supplement, 25 long-term care, basic hospital and medical-surgical expense 26 coverage as defined by the commissioner of insurance, 27 disability income insurance coverage, coverage issued as a 28 supplement to liability insurance, workers’ compensation or 29 similar insurance, or automobile medical payment insurance. 30 4. The commissioner of insurance may adopt rules pursuant to 31 chapter 17A to administer this section. 32 Sec. 2. APPLICABILITY. This Act applies to third-party 33 payment provider contracts, policies, or plans delivered, 34 issued for delivery, continued, or renewed in this state on or 35 -2- LSB 1639YH (2) 89 ko/rn 2/ 4

H.F. 873 after January 1, 2022. 1 EXPLANATION 2 The inclusion of this explanation does not constitute agreement with 3 the explanation’s substance by the members of the general assembly. 4 This bill relates to insurance coverage for prescription 5 drugs used in the treatment of stage IV cancer. 6 The bill requires policies, contracts, or plans providing 7 for third-party payment or prepayment of health or medical 8 expenses that provide coverage for prescription drugs to 9 provide coverage for prescription cancer drugs. “Prescription 10 cancer drug” is defined in the bill as a prescription drug that 11 is used to treat stage IV cancer. “Stage IV cancer” is also 12 defined in the bill. 13 The policy, contract, or plan is required to provide 14 coverage, without imposing a step therapy protocol, for a 15 prescription cancer drug that has been approved by the United 16 States food and drug administration, the use of which is 17 in accordance with medical standards of care for stage IV 18 cancer, and the use of which is supported by peer-reviewed, 19 evidence-based literature. The policy, contract, or plan must 20 provide coverage, and may impose a step therapy protocol, 21 for a prescription drug that is used to treat “associated 22 conditions”. “Associated conditions” is defined in the bill 23 as symptoms or side effects associated with stage IV cancer, 24 or with the health care services for stage IV cancer provided 25 by a covered person’s health care professional. “Step therapy 26 protocol” is defined in the bill as a protocol or program that 27 establishes a specific sequence in which prescription drugs for 28 a specified medical condition and medically appropriate for 29 a particular covered person are covered under a pharmacy or 30 medical benefit by a health carrier, a health benefit plan, or 31 a utilization review organization, including self-administered 32 drugs and drugs administered by a health care professional. 33 The bill applies to the third-party payment providers 34 enumerated in the bill. The bill specifies the types of 35 -3- LSB 1639YH (2) 89 ko/rn 3/ 4

H.F. 873 specialized health-related insurance which are not subject to 1 the bill. 2 The commissioner of insurance may adopt rules to administer 3 the requirements of the bill. 4 The provisions of the bill are applicable to third-party 5 payment provider contracts, policies, or plans delivered, 6 issued for delivery, continued, or renewed in this state on or 7 after January 1, 2022. 8 -4- LSB 1639YH (2) 89 ko/rn 4/ 4