Effective 01 Jan 2015, see footnote

376.1257. Orally administered anticancer medications, plan to provide coverage no less favorable than IV or injected medications — definitions — requirements — effective date. — 1. As used in this section the following terms shall mean:

(1) "Anticancer medications", medications used to kill or slow the growth of cancerous cells;

(2) "Covered person", a policyholder, subscriber, enrollee, or other individual enrolled in or insured by a health benefit plan for health insurance coverage;

(3) "Health benefit plan", shall have the same meaning as defined in section 376.1350.

2. Any health benefit plan that provides coverage and benefits for cancer treatment shall provide coverage of prescribed orally administered anticancer medications on a basis no less favorable than intravenously administered or injected anticancer medications.

3. Coverage of orally administered anticancer medication shall not be subject to any prior authorization, dollar limit, co-payment, deductible, or other out-of-pocket expense that does not apply to intravenously administered or injected anticancer medication, regardless of formulation or benefit category determination by the company administering the health benefit plan.

4. The health benefit plan shall not reclassify or increase any type of cost-sharing to the covered person for anticancer medications in order to achieve compliance with this section. Any change in health insurance coverage, which otherwise increases an out-of-pocket expense to anticancer medications, shall be applied to the majority of comparable medical or pharmaceutical benefits covered by the health benefit plan.

5. Notwithstanding the provisions of subsections 2, 3, and 4 of this section, a health benefit plan that limits the total amounts paid by a covered person through all cost-sharing requirements to no more than seventy-five dollars per thirty-day supply for any orally administered anticancer medication shall be considered in compliance with this section. On January 1, 2016, and on January first of each year thereafter, a health benefit plan may adjust such seventy-five dollar limit. The adjustment shall not exceed the Consumer Price Index for All Urban Consumers Midwest Region for that year. For purposes of this subsection "cost-sharing requirements" shall include co-payments, coinsurance, deductibles, and any other amounts paid by the covered person for that prescription.

6. For a health benefit plan that meets the definition of "high deductible health plan" as defined by 26 U.S.C. 223(c)(2), the provisions of subsection 5 of this section shall only apply after a covered person's deductible has been satisfied for the year.

7. The provisions of this section shall become effective January 1, 2015.

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(L. 2014 S.B. 668)

Effective 1-01-15