SF 197 (LSB 2512XS (1) 91)

SENATE FILE 197

BY  SWEENEY

A BILL FOR

An Act relating to insurance coverage for prescription drugs used in the treatment of metastatic cancer and associated conditions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.24A  Prescription drugs —— metastatic cancer and associated conditions.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Associated conditions” means symptoms or side effects associated with metastatic cancer, or with the health care services for metastatic cancer provided by a covered person’s health care professional and which in the judgment of the covered person’s health professional jeopardizes the health of the covered person.
   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.  “Metastatic cancer” means cancer that has spread from the primary or original site of the cancer to tissue, lymph nodes, or other parts of the body. Metastatic cancer may also be referred to as advanced cancer or stage 4 cancer.
   f.  “Prescription cancer drug” means a prescription drug that is used for the treatment of metastatic cancer or associated conditions. 
   g.  “Prescription drug” means a prescription drug that has been prescribed as medically necessary by a covered person’s health care professional. 
   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 metastatic cancer or associated conditions.
   (2)  The use of the prescription cancer drug for metastatic cancer and associated conditions 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 applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2026:
   (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 may adopt rules pursuant to chapter 17A to administer this section.
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 metastatic 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 metastatic cancer or associated conditions. “Metastatic 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 metastatic cancer and associated conditions, and the use of which is supported by peer-reviewed, evidence-based literature. “Associated conditions” is defined in the bill. “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 may 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, 2026.