On July 8, 2016, House Bill 60 was signed into law by Governor Wolf as Act 73. The legislation requires health insurance companies to provide coverage for oral chemotherapy medications or impose cost sharing on a no less favorable basis than intravenous (IV) or injected chemotherapy medications for cancer patients. The new law is intended to establish a level of parity for patients regardless of the type of cancer chemotherapy medication they are being prescribed – oral medication or injected medication. It is important for consumers to understand the practical implications of the new law. The following are some points to keep in mind:
• The legislation applies only if a health insurance policy already includes coverage for IV or injected chemotherapy medications that are FDA-approved.
• Under the law, insurers are prohibited from increasing cost sharing for chemotherapy medications for the purpose of avoiding complying with the law. Cost sharing examples include a co-payment, coinsurance or other out-of-pocket expense a consumer may have as required under their health insurance policy.
• Oral chemotherapy medications may be subject to a health insurance plan’s prior authorization requirements. This means that the health insurance plan may require the provider who is treating the patient to get prior approval from the health insurance company before medication is dispensed to the patient. The law allows the health insurance company to consider both the medical necessity and cost of the oral chemotherapy medication in comparison to IV or injected chemotherapy medication when making a prior authorization determination.
• The specific number and type of oral chemotherapy medications that are covered may vary by insurer and type of health plan.
It is also important to note which types of health insurance plans fall under the new law and the effective date. Act 73 applies to health insurance plans purchased by individuals as well as fully-insured small and large group plans offered by employers. The Act does not apply to self-funded plans. For those with insurance provided by their employer, it is best to check with the employer to inquire if the health insurance plan is self-funded.
The new law is effective for plans issued or renewed on or after January 8, 2017 for fully-insured large group health plans. For individual and small group plans, Act 73 is effective on or after January 1, 2018.
It is recommended that consumers check with their health insurance company to determine specifically how the new law applies to their particular coverage.