Health insurance issuers covering cancer treatment must cover prescribed oral anti-cancer medicines on terms no less favorable than injected or IV cancer medicines, with no extra prior authorization or cost-sharing that does not also apply to those other medicines.
§999.1. Parity for orally administered anti-cancer medications with intravenously administered or injected anti-cancer medications A. It is hereby declared that the public policy of this state is that every person within this state with health insurance coverage that provides coverage for cancer treatment shall have access to the type of covered medication used to treat his cancer, as such a decision affects the person's overall, long-term health and quality of life. It is also declared that orally administered anti-cancer medications, although very effective in killing or slowing the growth of cancerous cells, have high out-of-pocket costs to the covered person, impacting the decision of physicians to prescribe such medications, thus restricting patient access to life-saving oral anti-cancer medications. It is further declared that physicians must be able to make the best choice for their patients, considering the unique aspects of each patient and the progress of the disease. B.(1) A health insurance issuer that provides coverage for cancer treatment shall provide for coverage of prescribed orally administered anti-cancer medications on a basis no less favorable than intravenously administered or injected cancer medications. (2) Health insurance coverage of orally administered anti-cancer medications shall not be subject to any prior authorization, dollar limit, copayment, deductible, or other out-of-pocket expense that does not apply to intravenously administered or injected cancer medications, regardless of formulation or benefit category determination by the health insurance issuer. (3) A health insurance issuer shall not reclassify or increase any type of cost-sharing to the covered person for anti-cancer medications in order to achieve compliance with this Section. Any change in health insurance coverage that otherwise increases an out-of-pocket expense applied to anti-cancer medications shall also be applied to the majority of comparable medical or pharmaceutical benefits covered by the health insurance issuer. (4) A health insurance issuer that limits the total amount paid by a covered person through all cost-sharing requirements to no more than one hundred dollars per filled prescription for any orally administered anti-cancer medication shall be considered in compliance with this Section. For purposes of this Paragraph, "cost-sharing requirements" shall include copayments, coinsurance, deductibles, and any other amounts paid by the covered person for that prescription. C. As used in this Section: (1) "Anti-cancer medications" means medications used to kill or slow the growth of cancer cells. (2) "Covered person" means a policyholder, subscriber, enrollee, or other individual enrolled in or insured by a health insurance issuer for health insurance coverage. (3) "Health insurance coverage" or "coverage" means benefits consisting of medical care provided or arranged for directly, through insurance or reimbursement, or through a network, and including services paid for as medical care under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization agreement, or health maintenance organization contract offered by a health insurance issuer. (4) "Health insurance issuer" means any entity that offers health insurance coverage through a policy or certificate of insurance subject to state law that regulates the business of insurance. For purposes of this Section, a "health insurance issuer" shall include a health maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, nonfederal government plans subject to the provisions of Subpart B of this Part, and the Office of Group Benefits. (5) "Network of providers" or "network" means an entity other than a health insurance issuer that, through contracts with health care providers, provides or arranges for access by groups of covered persons to covered health care services by health care providers who are not otherwise or individually contracted directly with a health insurance issuer. D. The provisions of this Section shall not apply to the following: (1) Limited benefit health insurance policies or contracts. (2) High deductible health plans or policies that are qualified to be used in conjunction with a health savings account, a medical savings account, or other similar program authorized by 26 U.S.C. 220 et seq. (3) Qualified health plans offered through a health benefit exchange. Acts 2012, No. 410, §1. NOTE: See Acts 2012, No. 410, §2, relative to applicability.