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Senate File 116 - IntroducedA Bill ForAn Act 1relating to insurance coverage for prescription drugs
2used in the treatment of metastatic cancer and associated
3conditions, and including applicability provisions.
4BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 514C.24A Prescription drugs —
2metastatic cancer and associated conditions.
31. As used in this section, unless the context otherwise
4requires:
5a. “Associated conditions” means symptoms or side effects
6associated with metastatic cancer, or with the health care
7services for metastatic cancer provided by a covered person’s
8health care professional and which in the judgment of the
9covered person’s health professional jeopardizes the health of
10the covered person.
11b. “Covered person” means a policyholder, subscriber, or
12other person participating in a policy, contract, or plan that
13provides for third-party payment or prepayment of health or
14medical expenses that provides coverage for prescription drugs.
15c. “Health care professional” means the same as defined in
16section 514J.102.
17d. “Health care services” means services for the diagnosis,
18prevention, treatment, cure, or relief of a health condition,
19illness, injury, or disease.
20e. “Metastatic cancer” means cancer that has spread from
21the primary or original site of the cancer to tissue, lymph
22nodes, or other parts of the body. Metastatic cancer may also
23be referred to as advanced cancer or stage 4 cancer.
24f. “Prescription cancer drug” means a prescription drug that
25is used for the treatment of metastatic cancer or associated
26conditions.
27g. “Prescription drug” means a prescription drug that has
28been prescribed as medically necessary by a covered person’s
29health care professional.
30h. “Step therapy protocol” means the same as defined in
31section 514F.7.
322. a. Notwithstanding the uniformity of treatment
33requirements of section 514C.6, a policy, contract, or plan
34providing for third-party payment or prepayment of health or
35medical expenses that provides coverage for prescription drugs
-1-1shall provide coverage for prescription cancer drugs.
2b. Notwithstanding section 514F.7, the policy, contract, or
3plan shall provide coverage, without imposing a step therapy
4protocol, for a prescription cancer drug that meets all of the
5following requirements:
6(1) The use of the prescription cancer drug is in accordance
7with the medical standards of care for metastatic cancer or
8associated conditions.
9(2) The use of the prescription cancer drug for metastatic
10cancer and associated conditions is supported by peer-reviewed,
11evidence-based literature.
12(3) The prescription cancer drug has been approved by the
13United States food and drug administration.
143. a. This section shall apply to the following classes of
15third-party payment provider contracts, policies, or plans:
16(1) Individual or group accident and sickness insurance
17providing coverage on an expense-incurred basis.
18(2) An individual or group hospital or medical service
19contract issued pursuant to chapter 509, 514, or 514A.
20(3) An individual or group health maintenance organization
21contract regulated under chapter 514B.
22(4) A plan established for public employees pursuant to
23chapter 509A.
24b. This section shall not apply to accident-only, specified
25disease, short-term hospital or medical, hospital confinement
26indemnity, credit, dental, vision, Medicare supplement,
27long-term care, basic hospital and medical-surgical expense
28coverage as defined by the commissioner of insurance,
29disability income insurance coverage, coverage issued as a
30supplement to liability insurance, workers’ compensation or
31similar insurance, or automobile medical payment insurance.
324. The commissioner of insurance may adopt rules pursuant to
33chapter 17A to administer this section.
34 Sec. 2. APPLICABILITY. This Act applies to third-party
35payment provider contracts, policies, or plans delivered,
-2-1issued for delivery, continued, or renewed in this state on or
2after January 1, 2022.
3EXPLANATION
4The inclusion of this explanation does not constitute agreement with
5the explanation’s substance by the members of the general assembly.
6This bill relates to insurance coverage for prescription
7drugs used in the treatment of metastatic cancer.
8The bill requires policies, contracts, or plans providing
9for third-party payment or prepayment of health or medical
10expenses that provide coverage for prescription drugs to
11provide coverage for prescription cancer drugs. “Prescription
12cancer drug” is defined in the bill as a prescription drug that
13is used to treat metastatic cancer or associated conditions.
14“Metastatic cancer” is also defined in the bill.
15 The policy, contract, or plan is required to provide
16coverage, without imposing a step therapy protocol, for a
17prescription cancer drug that has been approved by the United
18States food and drug administration, the use of which is in
19accordance with medical standards of care for metastatic cancer
20and associated conditions, and the use of which is supported
21by peer-reviewed, evidence-based literature. “Associated
22conditions” is defined in the bill. “Step therapy protocol” is
23defined in the bill as a protocol or program that establishes a
24specific sequence in which prescription drugs for a specified
25medical condition and medically appropriate for a particular
26covered person are covered under a pharmacy or medical benefit
27by a health carrier, a health benefit plan, or a utilization
28review organization, including self-administered drugs and
29drugs administered by a health care professional.
30The bill applies to the third-party payment providers
31enumerated in the bill. The bill specifies the types of
32specialized health-related insurance which are not subject to
33the coverage requirements of the bill.
34The commissioner of insurance may adopt rules to administer
35the requirements of the bill.
-3- 1The provisions of the bill are applicable to third-party
2payment provider contracts, policies, or plans delivered,
3issued for delivery, continued, or renewed in this state on or
4after January 1, 2022.
-4-ko/rn
2used in the treatment of metastatic cancer and associated
3conditions, and including applicability provisions.
4BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 514C.24A Prescription drugs —
2metastatic cancer and associated conditions.
31. As used in this section, unless the context otherwise
4requires:
5a. “Associated conditions” means symptoms or side effects
6associated with metastatic cancer, or with the health care
7services for metastatic cancer provided by a covered person’s
8health care professional and which in the judgment of the
9covered person’s health professional jeopardizes the health of
10the covered person.
11b. “Covered person” means a policyholder, subscriber, or
12other person participating in a policy, contract, or plan that
13provides for third-party payment or prepayment of health or
14medical expenses that provides coverage for prescription drugs.
15c. “Health care professional” means the same as defined in
16section 514J.102.
17d. “Health care services” means services for the diagnosis,
18prevention, treatment, cure, or relief of a health condition,
19illness, injury, or disease.
20e. “Metastatic cancer” means cancer that has spread from
21the primary or original site of the cancer to tissue, lymph
22nodes, or other parts of the body. Metastatic cancer may also
23be referred to as advanced cancer or stage 4 cancer.
24f. “Prescription cancer drug” means a prescription drug that
25is used for the treatment of metastatic cancer or associated
26conditions.
27g. “Prescription drug” means a prescription drug that has
28been prescribed as medically necessary by a covered person’s
29health care professional.
30h. “Step therapy protocol” means the same as defined in
31section 514F.7.
322. a. Notwithstanding the uniformity of treatment
33requirements of section 514C.6, a policy, contract, or plan
34providing for third-party payment or prepayment of health or
35medical expenses that provides coverage for prescription drugs
-1-1shall provide coverage for prescription cancer drugs.
2b. Notwithstanding section 514F.7, the policy, contract, or
3plan shall provide coverage, without imposing a step therapy
4protocol, for a prescription cancer drug that meets all of the
5following requirements:
6(1) The use of the prescription cancer drug is in accordance
7with the medical standards of care for metastatic cancer or
8associated conditions.
9(2) The use of the prescription cancer drug for metastatic
10cancer and associated conditions is supported by peer-reviewed,
11evidence-based literature.
12(3) The prescription cancer drug has been approved by the
13United States food and drug administration.
143. a. This section shall apply to the following classes of
15third-party payment provider contracts, policies, or plans:
16(1) Individual or group accident and sickness insurance
17providing coverage on an expense-incurred basis.
18(2) An individual or group hospital or medical service
19contract issued pursuant to chapter 509, 514, or 514A.
20(3) An individual or group health maintenance organization
21contract regulated under chapter 514B.
22(4) A plan established for public employees pursuant to
23chapter 509A.
24b. This section shall not apply to accident-only, specified
25disease, short-term hospital or medical, hospital confinement
26indemnity, credit, dental, vision, Medicare supplement,
27long-term care, basic hospital and medical-surgical expense
28coverage as defined by the commissioner of insurance,
29disability income insurance coverage, coverage issued as a
30supplement to liability insurance, workers’ compensation or
31similar insurance, or automobile medical payment insurance.
324. The commissioner of insurance may adopt rules pursuant to
33chapter 17A to administer this section.
34 Sec. 2. APPLICABILITY. This Act applies to third-party
35payment provider contracts, policies, or plans delivered,
-2-1issued for delivery, continued, or renewed in this state on or
2after January 1, 2022.
3EXPLANATION
4The inclusion of this explanation does not constitute agreement with
5the explanation’s substance by the members of the general assembly.
6This bill relates to insurance coverage for prescription
7drugs used in the treatment of metastatic cancer.
8The bill requires policies, contracts, or plans providing
9for third-party payment or prepayment of health or medical
10expenses that provide coverage for prescription drugs to
11provide coverage for prescription cancer drugs. “Prescription
12cancer drug” is defined in the bill as a prescription drug that
13is used to treat metastatic cancer or associated conditions.
14“Metastatic cancer” is also defined in the bill.
15 The policy, contract, or plan is required to provide
16coverage, without imposing a step therapy protocol, for a
17prescription cancer drug that has been approved by the United
18States food and drug administration, the use of which is in
19accordance with medical standards of care for metastatic cancer
20and associated conditions, and the use of which is supported
21by peer-reviewed, evidence-based literature. “Associated
22conditions” is defined in the bill. “Step therapy protocol” is
23defined in the bill as a protocol or program that establishes a
24specific sequence in which prescription drugs for a specified
25medical condition and medically appropriate for a particular
26covered person are covered under a pharmacy or medical benefit
27by a health carrier, a health benefit plan, or a utilization
28review organization, including self-administered drugs and
29drugs administered by a health care professional.
30The bill applies to the third-party payment providers
31enumerated in the bill. The bill specifies the types of
32specialized health-related insurance which are not subject to
33the coverage requirements of the bill.
34The commissioner of insurance may adopt rules to administer
35the requirements of the bill.
-3- 1The provisions of the bill are applicable to third-party
2payment provider contracts, policies, or plans delivered,
3issued for delivery, continued, or renewed in this state on or
4after January 1, 2022.
-4-ko/rn