House File 873 - Introduced
HOUSE FILE 873
BY GAINES and THEDE
A BILL FOR
1 An Act relating to insurance coverage for prescription drugs
2 used in the treatment of stage IV cancer, and including
3 applicability provisions.
4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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1 Section 1. NEW SECTION. 514C.24A Prescription drugs ——
2 stage IV cancer.
3 1. As used in this section, unless the context otherwise
4 requires:
5 a. “Associated conditions” means symptoms or side effects
6 associated with stage IV cancer, or with the health care
7 services for stage IV cancer provided by a covered person’s
8 health care professional.
9 b. “Covered person” means a policyholder, subscriber, or
10 other person participating in a policy, contract, or plan that
11 provides for third-party payment or prepayment of health or
12 medical expenses that provides coverage for prescription drugs.
13 c. “Health care professional” means the same as defined in
14 section 514J.102.
15 d. “Health care services” means services for the diagnosis,
16 prevention, treatment, cure, or relief of a health condition,
17 illness, injury, or disease.
18 e. “Prescription cancer drug” means a prescription drug that
19 is used for the treatment of stage IV cancer.
20 f. “Prescription drug” means a prescription drug that has
21 been prescribed as medically necessary by a covered person’s
22 health care professional.
23 g. “Stage IV cancer” means cancer that has spread from the
24 primary or original site of the cancer to other parts of the
25 body. Stage IV cancer may also be referred to as advanced
26 cancer or metastatic cancer.
27 h. “Step therapy protocol” means the same as defined in
28 section 514F.7.
29 2. a. Notwithstanding the uniformity of treatment
30 requirements of section 514C.6, a policy, contract, or plan
31 providing for third-party payment or prepayment of health or
32 medical expenses that provides coverage for prescription drugs
33 shall provide coverage for prescription cancer drugs.
34 b. Notwithstanding section 514F.7, the policy, contract, or
35 plan shall provide coverage, without imposing a step therapy
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1 protocol, for a prescription cancer drug that meets all of the
2 following requirements:
3 (1) The use of the prescription cancer drug is in accordance
4 with the medical standards of care for stage IV cancer.
5 (2) The use of the prescription cancer drug for stage
6 IV cancer is supported by peer-reviewed, evidence-based
7 literature.
8 (3) The prescription cancer drug has been approved by the
9 United States food and drug administration.
10 c. The policy, contract, or plan shall provide coverage,
11 and may impose a step therapy protocol, for a prescription drug
12 that is used to treat associated conditions.
13 3. a. This section shall apply to the following classes of
14 third-party payment provider contracts, policies, or plans:
15 (1) Individual or group accident and sickness insurance
16 providing coverage on an expense-incurred basis.
17 (2) An individual or group hospital or medical service
18 contract issued pursuant to chapter 509, 514, or 514A.
19 (3) An individual or group health maintenance organization
20 contract regulated under chapter 514B.
21 (4) A plan established for public employees pursuant to
22 chapter 509A.
23 b. This section shall not apply to accident-only, specified
24 disease, short-term hospital or medical, hospital confinement
25 indemnity, credit, dental, vision, Medicare supplement,
26 long-term care, basic hospital and medical-surgical expense
27 coverage as defined by the commissioner of insurance,
28 disability income insurance coverage, coverage issued as a
29 supplement to liability insurance, workers’ compensation or
30 similar insurance, or automobile medical payment insurance.
31 4. The commissioner of insurance may adopt rules pursuant to
32 chapter 17A to administer this section.
33 Sec. 2. APPLICABILITY. This Act applies to third-party
34 payment provider contracts, policies, or plans delivered,
35 issued for delivery, continued, or renewed in this state on or
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1 after January 1, 2022.
2 EXPLANATION
3 The inclusion of this explanation does not constitute agreement with
4 the explanation’s substance by the members of the general assembly.
5 This bill relates to insurance coverage for prescription
6 drugs used in the treatment of stage IV cancer.
7 The bill requires policies, contracts, or plans providing
8 for third-party payment or prepayment of health or medical
9 expenses that provide coverage for prescription drugs to
10 provide coverage for prescription cancer drugs. “Prescription
11 cancer drug” is defined in the bill as a prescription drug that
12 is used to treat stage IV cancer. “Stage IV cancer” is also
13 defined in the bill.
14 The policy, contract, or plan is required to provide
15 coverage, without imposing a step therapy protocol, for a
16 prescription cancer drug that has been approved by the United
17 States food and drug administration, the use of which is
18 in accordance with medical standards of care for stage IV
19 cancer, and the use of which is supported by peer-reviewed,
20 evidence-based literature. The policy, contract, or plan must
21 provide coverage, and may impose a step therapy protocol,
22 for a prescription drug that is used to treat “associated
23 conditions”. “Associated conditions” is defined in the bill
24 as symptoms or side effects associated with stage IV cancer,
25 or with the health care services for stage IV cancer provided
26 by a covered person’s health care professional. “Step therapy
27 protocol” is defined in the bill as a protocol or program that
28 establishes a specific sequence in which prescription drugs for
29 a specified medical condition and medically appropriate for
30 a particular covered person are covered under a pharmacy or
31 medical benefit by a health carrier, a health benefit plan, or
32 a utilization review organization, including self-administered
33 drugs and drugs administered by a health care professional.
34 The bill applies to the third-party payment providers
35 enumerated in the bill. The bill specifies the types of
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1 specialized health-related insurance which are not subject to
2 the bill.
3 The commissioner of insurance may adopt rules to administer
4 the requirements of the bill.
5 The provisions of the bill are applicable to third-party
6 payment provider contracts, policies, or plans delivered,
7 issued for delivery, continued, or renewed in this state on or
8 after January 1, 2022.
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