2
3
4
5
6
7 LONG TITLE
8 General Description:
9 This bill amends provisions relating to health insurance coverage for certain cancer
10 treatments.
11 Highlighted Provisions:
12 This bill:
13 ▸ defines terms; and
14 ▸ prohibits a health benefit plan from requiring step therapy for certain drugs used to
15 treat cancer or associated conditions.
16 Money Appropriated in this Bill:
17 None
18 Other Special Clauses:
19 None
20 Utah Code Sections Affected:
21 AMENDS:
22 31A-22-641, as enacted by Laws of Utah 2013, Chapter 164
23
24 Be it enacted by the Legislature of the state of Utah:
25 Section 1. Section 31A-22-641 is amended to read:
26 31A-22-641. Cancer treatment parity -- prohibition on step therapy for certain
27 cancer treatments.
28 (1) For purposes of this section:
29 (a) "Cost sharing" means the enrollee's maximum out-of-pocket costs as defined by the
30 health benefit plan.
31 (b) "Health insurer" [
32 (c) "Intravenously administered chemotherapy" means a physician-prescribed cancer
33 treatment that is used to kill or slow the growth of cancer cells, that is administered through
34 injection directly into the patient's circulatory system by a physician, physician assistant, nurse
35 practitioner, nurse, or other medical personnel under the supervision of a physician, and in a
36 hospital, medical office, or other clinical setting.
37 (d) "Oral chemotherapy" means a United States Food and Drug
38 Administration-approved, physician-prescribed cancer treatment that is used to kill or slow the
39 growth of cancer cells, that is taken orally in the form of a tablet or capsule, and may be
40 administered in a hospital, medical office, or other clinical setting or may be delivered to the
41 patient for self-administration under the direction or supervision of a physician outside of a
42 hospital, medical office, or other clinical setting.
43 (e) "Relapsed or refractory hematologic cancer" means a cancer that is unlikely to be
44 cured or controlled with treatment.
45 (f) "Stage IV metastatic cancer" means cancer that has spread from the primary or
46 original site to other organs, distant sites, tissues, or other parts of the body.
47 (2) (a) This section applies to health benefit plans renewed or entered into on or after
48 October 1, 2013.
49 [
50 intravenously administered chemotherapy shall:
51 [
52 applied to the covered oral chemotherapy is no more restrictive than the cost sharing applied to
53 the covered intravenously administered chemotherapy; or
54 [
55 sharing for intravenous chemotherapy, the health benefit plan may not apply cost sharing for
56 the oral chemotherapy that exceeds $300 per filled prescription.
57 (3) (a) This Subsection (3) applies to a health benefit plan entered into or renewed on
58 or after January 1, 2021.
59 (b) A health insurer or a pharmacy benefit manager may not require a step therapy
60 protocol for coverage or a prescription drug or a sequence of prescription drugs if:
61 (i) the recommended prescription drug or sequence of prescription drugs is prescribed
62 to treat the enrollee's:
63 (A) stage IV metastatic cancer;
64 (B) relapsed or refractory hematologic cancer; or
65 (C) severe side effects of the cancers described in Subsection (3)(b)(ii)(A) or (B),
66 including anemia, neutropenia, bone complications, nausea, vomiting, oral mucositis, diarrhea,
67 skin toxicity, peripheral neurotoxicity, and pain; and
68 (ii) the use of the prescription drug or series of prescription drugs is:
69 (A) indicated by the United States Food and Drug Administration for treatment of the
70 enrollee's condition under Subsection (3)(b)(i); or
71 (B) supported by peer-reviewed medical literature.
72 (c) This Subsection (3) does not require coverage of a prescription drug that is not on
73 the insurer's prescription drug formulary.
74 (4) (a) A health insurer [
75 administered chemotherapy for the purpose of achieving compliance with this section.
76 (b) The commissioner may adopt administrative rules in accordance with Title 63G,
77 Chapter 3, Utah Administrative Rulemaking Act, to enforce the provisions of this section.