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:
16 Other Special Clauses:
18 Utah Code Sections Affected:
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" [
30 Section 31A-22-634[
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 [
51 into on or after October 1, 2013.
53 intravenously administered chemotherapy shall:
55 applied to the covered oral chemotherapy is no more restrictive than the cost sharing applied to
56 the covered intravenously administered chemotherapy; or
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.
61 intravenously administered chemotherapy for the purpose of achieving compliance with this
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
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.