23-79-147. Prescription medication — Definitions.

23-79-147. Prescription medication — Definitions. (a) As used in this section: (1) “Commissioner” means the Insurance Commissioner of the State Insurance Department; (2) “Insurance policy” means any individual, group, or blanket policy, contract, or evidence of coverage written, issued, amended, delivered, or renewed in this state, or which provides such insurance for residents of this state by an insurance company, hospital medical corporation, or health maintenance organization; (3) “Medical literature” means articles from major peer-reviewed medical journals specified by the United States Department of Health and Human Services pursuant to section 1861(t)(2)(B) of the Social Security Act, 107 Stat. 591 (1993), 42 U.S.C. § 1395x(t)(2)(B), as amended; and (4) “Metastatic cancer” means cancer that has spread from a primary or original site of the cancer to surrounding or nearby tissues, lymph nodes, or other parts of the body. (b) An insurance policy that provides coverage for prescription drugs shall not limit or exclude coverage for any drug approved by the United States Food and Drug Administration for use in the treatment of cancer on the basis that the drug has not been approved by the United States Food and Drug Administration for the treatment of the specific type of cancer for which the drug has been prescribed if: (1) The drug has been recognized as safe and effective for treatment of that specific type of cancer in any of the following standard reference compendia, unless the use is identified as not indicated in one (1) or more of these standard reference compendia: (A)(i) The American Hospital Formulary Service Drug Information; (ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium; (iii) The Elsevier Gold Standard's Clinical Pharmacology; or (B) The drug has been recognized as safe and effective for treatment of that specific type of cancer in two (2) articles from medical literature that have not had their recognition of the drug's safety and effectiveness contradicted by clear and convincing evidence presented in another article from medical literature; or (2) Other authoritative compendia as identified by the Secretary of the United States Department of Health and Human Services or the commissioner may be used to provide coverage by an insurer at the insurer's discretion. (c) Coverage of a drug required by subsection (b) of this section includes medically necessary services associated with the administration of the drug, provided that such services are covered by the insurance policy. (d) Except as provided in subsection (e) of this section, subsection (b) of this section shall not be construed to do any of the following: (1) Require coverage for any drug if the United States Food and Drug Administration has determined its use to be contraindicated for the treatment of the specific type of cancer for which the drug has been prescribed; (2) Alter any law with regard to provisions limiting the coverage of drugs that have not been approved by the United States Food and Drug Administration; or (3) Create, impair, alter, limit, modify, enlarge, abrogate, or prohibit reimbursement for drugs used in the treatment of any other disease or condition. (e) An insurance policy that provides coverage for the treatment of metastatic cancer shall not limit or exclude coverage under the health benefit plan for a drug approved by the United States Food and Drug Administration that is on the prescription drug formulary of the insurance policy by mandating that a covered person with metastatic cancer undergo step therapy unless the preferred drug is consistent with best practices that: (1) Are used for the treatment of metastatic cancer or associated conditions under: (A) The United States Food and Drug Administration-approved indication; or (B) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or (2) Use evidence-based, peer-reviewed, recognized medical literature.