Relating to insurance coverage for diagnostic breast cancer examinations and prescription drugs used in the treatment of stage IV cancer, and including applicability provisions

The examination may be conducted using a diagnostic mammogram, breast magnetic resonance imaging, or breast ultrasound. “Abnormality”, “diagnostic mammogram”, “breast magnetic resonance imaging”, and “breast ultrasound” are also defined in the bill. The policy, contract, or plan cannot require cost-sharing greater than the cost-sharing that the policy, contract, or plan requires for a screening mammogram. “Cost-sharing” and “screening mammogram” are defined in the bill. The bill also requires policies, contracts, or plans providing for third-party payment or prepayment of health or medical expenses that provide coverage for prescription drugs to provide coverage for prescription cancer drugs. “Prescription cancer drug” is defined in the bill as a prescription drug that is used to treat stage IV cancer. “Stage IV cancer” is also defined in the bill. The policy, contract, or plan is required to provide coverage, without imposing a step therapy protocol, for a prescription cancer drug that has been approved by the United States food and drug administration, the use of which is in accordance with medical standards of care for stage IV cancer, and the use of which is supported by peer-reviewed, evidence-based literature. “Step therapy protocol” is defined in the bill as a protocol or program that establishes a specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular covered person are covered under a pharmacy or medical benefit by a health carrier, a health benefit plan, or a utilization review organization, including self-administered drugs and drugs administered by a health care professional. The bill applies to third-party payment providers enumerated in the bill. The bill specifies the types of specialized health-related insurance which are not subject to the coverage requirements of the bill. The commissioner of insurance is required to adopt rules to administer the requirements of the bill. The bill applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2021.