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Senate
File
197
-
Introduced
SENATE
FILE
197
BY
SWEENEY
A
BILL
FOR
An
Act
relating
to
insurance
coverage
for
prescription
drugs
1
used
in
the
treatment
of
metastatic
cancer
and
associated
2
conditions.
3
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
4
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Section
1.
NEW
SECTION
.
514C.24A
Prescription
drugs
——
1
metastatic
cancer
and
associated
conditions.
2
1.
As
used
in
this
section,
unless
the
context
otherwise
3
requires:
4
a.
“Associated
conditions”
means
symptoms
or
side
effects
5
associated
with
metastatic
cancer,
or
with
the
health
care
6
services
for
metastatic
cancer
provided
by
a
covered
person’s
7
health
care
professional
and
which
in
the
judgment
of
the
8
covered
person’s
health
professional
jeopardizes
the
health
of
9
the
covered
person.
10
b.
“Covered
person”
means
a
policyholder,
subscriber,
or
11
other
person
participating
in
a
policy,
contract,
or
plan
that
12
provides
for
third-party
payment
or
prepayment
of
health
or
13
medical
expenses
that
provides
coverage
for
prescription
drugs.
14
c.
“Health
care
professional”
means
the
same
as
defined
in
15
section
514J.102.
16
d.
“Health
care
services”
means
services
for
the
diagnosis,
17
prevention,
treatment,
cure,
or
relief
of
a
health
condition,
18
illness,
injury,
or
disease.
19
e.
“Metastatic
cancer”
means
cancer
that
has
spread
from
20
the
primary
or
original
site
of
the
cancer
to
tissue,
lymph
21
nodes,
or
other
parts
of
the
body.
Metastatic
cancer
may
also
22
be
referred
to
as
advanced
cancer
or
stage
4
cancer.
23
f.
“Prescription
cancer
drug”
means
a
prescription
drug
that
24
is
used
for
the
treatment
of
metastatic
cancer
or
associated
25
conditions.
26
g.
“Prescription
drug”
means
a
prescription
drug
that
has
27
been
prescribed
as
medically
necessary
by
a
covered
person’s
28
health
care
professional.
29
h.
“Step
therapy
protocol”
means
the
same
as
defined
in
30
section
514F.7.
31
2.
a.
Notwithstanding
the
uniformity
of
treatment
32
requirements
of
section
514C.6,
a
policy,
contract,
or
plan
33
providing
for
third-party
payment
or
prepayment
of
health
or
34
medical
expenses
that
provides
coverage
for
prescription
drugs
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shall
provide
coverage
for
prescription
cancer
drugs.
1
b.
Notwithstanding
section
514F.7,
the
policy,
contract,
or
2
plan
shall
provide
coverage,
without
imposing
a
step
therapy
3
protocol,
for
a
prescription
cancer
drug
that
meets
all
of
the
4
following
requirements:
5
(1)
The
use
of
the
prescription
cancer
drug
is
in
accordance
6
with
the
medical
standards
of
care
for
metastatic
cancer
or
7
associated
conditions.
8
(2)
The
use
of
the
prescription
cancer
drug
for
metastatic
9
cancer
and
associated
conditions
is
supported
by
peer-reviewed,
10
evidence-based
literature.
11
(3)
The
prescription
cancer
drug
has
been
approved
by
the
12
United
States
food
and
drug
administration.
13
3.
a.
This
section
applies
to
the
following
classes
of
14
third-party
payment
provider
contracts,
policies,
or
plans
15
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
16
state
on
or
after
January
1,
2026:
17
(1)
Individual
or
group
accident
and
sickness
insurance
18
providing
coverage
on
an
expense-incurred
basis.
19
(2)
An
individual
or
group
hospital
or
medical
service
20
contract
issued
pursuant
to
chapter
509,
514,
or
514A.
21
(3)
An
individual
or
group
health
maintenance
organization
22
contract
regulated
under
chapter
514B.
23
(4)
A
plan
established
for
public
employees
pursuant
to
24
chapter
509A.
25
b.
This
section
shall
not
apply
to
accident-only,
specified
26
disease,
short-term
hospital
or
medical,
hospital
confinement
27
indemnity,
credit,
dental,
vision,
Medicare
supplement,
28
long-term
care,
basic
hospital
and
medical-surgical
expense
29
coverage
as
defined
by
the
commissioner
of
insurance,
30
disability
income
insurance
coverage,
coverage
issued
as
a
31
supplement
to
liability
insurance,
workers’
compensation
or
32
similar
insurance,
or
automobile
medical
payment
insurance.
33
4.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
34
chapter
17A
to
administer
this
section.
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EXPLANATION
1
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
2
the
explanation’s
substance
by
the
members
of
the
general
assembly.
3
This
bill
relates
to
insurance
coverage
for
prescription
4
drugs
used
in
the
treatment
of
metastatic
cancer.
5
The
bill
requires
policies,
contracts,
or
plans
providing
6
for
third-party
payment
or
prepayment
of
health
or
medical
7
expenses
that
provide
coverage
for
prescription
drugs
to
8
provide
coverage
for
prescription
cancer
drugs.
“Prescription
9
cancer
drug”
is
defined
in
the
bill
as
a
prescription
drug
that
10
is
used
to
treat
metastatic
cancer
or
associated
conditions.
11
“Metastatic
cancer”
is
also
defined
in
the
bill.
12
The
policy,
contract,
or
plan
is
required
to
provide
13
coverage,
without
imposing
a
step
therapy
protocol,
for
a
14
prescription
cancer
drug
that
has
been
approved
by
the
United
15
States
food
and
drug
administration,
the
use
of
which
is
in
16
accordance
with
medical
standards
of
care
for
metastatic
cancer
17
and
associated
conditions,
and
the
use
of
which
is
supported
18
by
peer-reviewed,
evidence-based
literature.
“Associated
19
conditions”
is
defined
in
the
bill.
“Step
therapy
protocol”
is
20
defined
in
the
bill
as
a
protocol
or
program
that
establishes
a
21
specific
sequence
in
which
prescription
drugs
for
a
specified
22
medical
condition
and
medically
appropriate
for
a
particular
23
covered
person
are
covered
under
a
pharmacy
or
medical
benefit
24
by
a
health
carrier,
a
health
benefit
plan,
or
a
utilization
25
review
organization,
including
self-administered
drugs
and
26
drugs
administered
by
a
health
care
professional.
27
The
bill
applies
to
the
third-party
payment
providers
28
enumerated
in
the
bill.
The
bill
specifies
the
types
of
29
specialized
health-related
insurance
which
are
not
subject
to
30
the
coverage
requirements
of
the
bill.
31
The
commissioner
of
insurance
may
adopt
rules
to
administer
32
the
requirements
of
the
bill.
33
The
provisions
of
the
bill
are
applicable
to
third-party
34
payment
provider
contracts,
policies,
or
plans
delivered,
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197
issued
for
delivery,
continued,
or
renewed
in
this
state
on
or
1
after
January
1,
2026.
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