§ 764b.1. Coverage for oral chemotherapy medications
Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: July 8, 2016
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.
“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:
(2) The act of December 29, 1972 (P.L. 1701, No. 364),1 known as the “Health Maintenance Organization Act.”
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 Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
End of Document |