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§ 764b.1. Coverage for oral chemotherapy medications

Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: July 8, 2016

Purdon's Pennsylvania Statutes and Consolidated Statutes
Title 40 P.S. Insurance (Refs & Annos)
Chapter 2. Insurance Companies (Refs & Annos)
Article VI. Casualty Insurance (Refs & Annos)
(b) Health and Accident Insurance (Refs & Annos)
Effective: July 8, 2016
40 P.S. § 764b.1
§ 764b.1. Coverage for oral chemotherapy medications
(a) Whenever a health insurance policy provides coverage that includes coverage for intravenously administered or injected chemotherapy medications which have been approved by the United States Food and Drug Administration for general use in the treatment of cancer, the policy shall not provide coverage or impose cost sharing for a prescribed, orally administered chemotherapy medication on a less favorable basis than the coverage it provides or cost sharing it imposes for intravenously administered or injected chemotherapy medications.
(b) A health insurance policy shall not increase cost sharing for chemotherapy medications in order to avoid compliance with subsection (a). A health insurance policy may increase cost sharing for chemotherapy medications if an increase is applied generally to other medical or pharmaceutical benefits administered in a similar health care setting under the contract.
(c) The prohibitions in subsections (a) and (b) do not preclude a health insurance policy from requiring an enrollee to obtain prior authorization before orally administered chemotherapy medication is dispensed to the enrollee. As part of prior authorization, an insurer may consider the medical necessity and cost of oral chemotherapy medications compared with intravenously administered or injected chemotherapy medication.
(d) This section shall apply to a high deductible health plan, as defined in section 223(c)(2) of the Internal Revenue Code of 1986 (Public Law 99-514, 26 U.S.C. § 223(c)(2)), only after the covered person's deductible has been satisfied for the year.
(e) This section shall apply to those health insurance policies issued or entered into or renewed on or after the effective date of this section.
(f) As used in this section:
“Chemotherapy medication” means a medication prescribed by a treating health care practitioner that is necessary to kill or slow the growth of cancerous cells.
“Cost sharing” means the cost to an individual insured under a health insurance policy according to any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense requirements imposed by the policy, contract or agreement.
“Health insurance policy” means any individual or group health, sickness or accident policy, or subscriber contract or certificate offered, issued or renewed by an entity subject to one of the following:
(1) This act.
(2) The act of December 29, 1972 (P.L. 1701, No. 364),1 known as the “Health Maintenance Organization Act.”
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations).
The term does not include accident only, fixed indemnity, limited benefit, credit, dental, vision, specified disease, Medicare supplement, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement, long-term care or disability income, workers' compensation or automobile medical payment insurance.

Credits

1921, May 17, P.L. 682, No. 284, § 631.1, added 2016, July 8, P.L. 474, No. 73, § 1, imd. effective.

Footnotes

40 P.S. § 1551 et seq.
40 P.S. § 764b.1, PA ST 40 P.S. § 764b.1
Current through 2022 Regular Session Act 121. Some statute sections may be more current, see credits for details.
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