1     
TREATMENT MEDICATION AMENDMENTS

2     
2019 GENERAL SESSION

3     
STATE OF UTAH

4     
Chief Sponsor: Karen Mayne

5     
House Sponsor: ____________

6     

7     LONG TITLE
8     General Description:
9          This bill amends provisions relating to health insurance coverage for cancer treatment.
10     Highlighted Provisions:
11          This bill:
12          ▸     prohibits a health benefit plan from requiring step therapy for certain drugs used to
13     treat stage-IV advanced metastatic cancer or associated conditions.
14     Money Appropriated in this Bill:
15          None
16     Other Special Clauses:
17          None
18     Utah Code Sections Affected:
19     AMENDS:
20          31A-22-641, as enacted by Laws of Utah 2013, Chapter 164
21     

22     Be it enacted by the Legislature of the state of Utah:
23          Section 1. Section 31A-22-641 is amended to read:
24          31A-22-641. Cancer treatment parity -- Prohibition on step therapy for certain
25     cancer treatment.
26          (1) For purposes of this section:
27          (a) "Cost sharing" means the enrollee's maximum out-of-pocket costs as defined by the
28     health benefit plan.
29          (b) "Health insurer" is as defined in Subsection 31A-22-634(1).
30          (c) "Intravenously administered chemotherapy" means a physician-prescribed cancer
31     treatment that is used to kill or slow the growth of cancer cells, that is administered through
32     injection directly into the patient's circulatory system by a physician, physician assistant, nurse
33     practitioner, nurse, or other medical personnel under the supervision of a physician, and in a
34     hospital, medical office, or other clinical setting.
35          (d) "Oral chemotherapy" means a United States Food and Drug
36     Administration-approved, physician-prescribed cancer treatment that is used to kill or slow the
37     growth of cancer cells, that is taken orally in the form of a tablet or capsule, and may be
38     administered in a hospital, medical office, or other clinical setting or may be delivered to the
39     patient for self-administration under the direction or supervision of a physician outside of a
40     hospital, medical office, or other clinical setting.
41          (2) (a) This [section] Subsection (2) applies to health benefit plans renewed or entered
42     into on or after October 1, 2013.
43          [(3)] (b) A health benefit plan that covers prescribed oral chemotherapy and
44     intravenously administered chemotherapy shall:
45          [(a)] (i) except as provided in Subsection [(3)(b)] (2)(b)(ii), ensure that the cost sharing
46     applied to the covered oral chemotherapy is no more restrictive than the cost sharing applied to
47     the covered intravenously administered chemotherapy; or
48          [(b)] (ii) if the cost sharing for oral chemotherapy is more restrictive than the cost
49     sharing for intravenous chemotherapy, the health benefit plan may not apply cost sharing for
50     the oral chemotherapy that exceeds $300 per filled prescription.
51          [(4) (a)] (c) (i) A health insurer shall not increase the cost sharing for intravenously
52     administered chemotherapy for the purpose of achieving compliance with this section.
53          [(b)] (ii) The commissioner may adopt administrative rules in accordance with Title
54     63G, Chapter 3, Utah Administrative Rulemaking Act, to enforce the provisions of this section.
55          (3) (a) This Subsection (3) applies to a health benefit plan entered into or renewed on
56     or after January 1, 2020.
57          (b) A health benefit plan may not make coverage of a prescription drug dependent on
58     the completion of a fail-first or other step therapy protocol if use of the prescription drug is:
59          (i) approved by the United States Food and Drug Administration;
60          (ii) indicated for treatment of stage-IV advanced metastatic cancer by:
61          (A) the United States Food and Drug Administration; or
62          (B) the National Comprehensive Cancer Network Drugs and Biologics Compendium;
63          (iii) for treatment of the enrollee's stage-IV advanced metastatic cancer or an associated
64     condition; and
65          (iv) supported by peer-reviewed medical literature.