Chief Sponsor: Karen Mayne

House Sponsor: ____________


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

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] means insurer as that term is defined in [Subsection]
30     Section 31A-22-634[(1)].
31          (c) "Intravenously administered chemotherapy" means a physician-prescribed cancer
32     treatment that is used to kill or slow the growth of cancer cells, that is administered through
33     injection directly into the patient's circulatory system by a physician, physician assistant, nurse
34     practitioner, nurse, or other medical personnel under the supervision of a physician, and in a
35     hospital, medical office, or other clinical setting.
36          (d) "Oral chemotherapy" means a United States Food and Drug
37     Administration-approved, physician-prescribed cancer treatment that is used to kill or slow the
38     growth of cancer cells, that is taken orally in the form of a tablet or capsule, and may be
39     administered in a hospital, medical office, or other clinical setting or may be delivered to the
40     patient for self-administration under the direction or supervision of a physician outside of a
41     hospital, medical office, or other clinical setting.
42          (e) "Qualified prescription drug" means a prescription drug that is:
43          (i) on the health benefit plan's formulary;
44          (ii) approved by the United States Food and Drug Administration;
45          (iii) indicated for treatment of stage-IV advanced metastatic cancer by:
46          (A) the United States Food and Drug Administration; or
47          (B) the National Comprehensive Cancer Network Drugs and Biologics Compendium;
48          (iv) for treatment of the enrollee's stage-IV advanced metastatic cancer; and
49          (v) supported by peer-reviewed medical literature.
50          (2) (a) This [section] Subsection (2) applies to health benefit plans renewed or entered
51     into on or after October 1, 2013.
52          [(3)] (b) A health benefit plan that covers prescribed oral chemotherapy and
53     intravenously administered chemotherapy shall:
54          [(a)] (i) except as provided in Subsection [(3)(b)] (2)(b)(ii), ensure that the cost sharing
55     applied to the covered oral chemotherapy is no more restrictive than the cost sharing applied to
56     the covered intravenously administered chemotherapy; or
57          [(b)] (ii) if the cost sharing for oral chemotherapy is more restrictive than the cost
58     sharing for intravenous chemotherapy, the health benefit plan may not apply cost sharing for

59     the oral chemotherapy that exceeds $300 per filled prescription.
60          [(4) (a)] (c) (i) A health insurer [shall] may not increase the cost sharing for
61     intravenously administered chemotherapy for the purpose of achieving compliance with this
62     section.
63          [(b)] (ii) The commissioner may adopt administrative rules in accordance with Title
64     63G, Chapter 3, Utah Administrative Rulemaking Act, to enforce the provisions of this section.
65          (3) (a) This Subsection (3) applies to a health benefit plan entered into or renewed on
66     or after January 1, 2021.
67          (b) A health benefit plan may not make coverage of a qualified prescription drug
68     dependent on more than two steps in a step therapy protocol.
69          (c) Notwithstanding Subsection (3)(b), a health benefit plan may not make coverage a
70     qualified prescription drug dependent on any step therapy protocol if the qualified prescription
71     drug is the only prescription drug on the health benefit plan's formulary that is approved by the
72     United States Food and Drug Administration as treatment for stage-IV advanced metastatic
73     cancer.
74          (d) This Subsection (3) does not:
75          (i) require coverage of a prescription drug that is not on the health benefit plan's
76     formulary; or
77          (ii) prohibit a health benefit plan from requiring the use of a biosimilar product before
78     the biologic originator.