20-2326. Drugs; cancer treatment; definitions
A. Any health benefits plan that is offered by an accountable health plan
and that provides coverage for prescription drugs shall not limit or exclude coverage for
any prescription drug prescribed for the treatment of cancer on the basis that the
prescription 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 prescription drug has been
prescribed, if the prescription drug has been recognized as safe and effective for
treatment of that specific type of cancer in one or more of the standard medical
reference compendia prescribed in subsection B or medical literature that meets the
criteria prescribed in subsection B. The coverage required under this subsection
includes covered medically necessary services associated with the administration of the
prescription drug. This subsection does not:
1. Require coverage of any prescription drug used in the treatment of a type of
cancer if the United States food and drug administration has determined that the
prescription drug is contraindicated for that type of cancer.
2. Require coverage for any experimental prescription drug that is not approved for
any indication by the United States food and drug administration.
3. Alter any law with regard to provisions that limit the coverage of prescription
drugs that have not been approved by the United States food and drug administration.
4. Require reimbursement or coverage for any prescription drug that is not included
in the drug formulary or list of covered prescription drugs specified in the health
benefits plan.
5. Prohibit a health benefits plan from limiting or excluding coverage of a
prescription drug, if the decision to limit or exclude coverage of the prescription drug
is not based primarily on the coverage of prescription drugs required by this section.
6. Prohibit the use of deductibles, coinsurance, copayments or other cost sharing
in relation to drug benefits and related medical benefits offered.
B. For the purposes of subsection A:
1. The acceptable standard medical reference compendia are the following:
(a) The American hospital formulary service drug information, a publication of the
American society of health system pharmacists.
(b) The national comprehensive cancer network drugs and biologics compendium.
(c) Thomson Micromedex compendium DrugDex.
(d) Elsevier gold standard's clinical pharmacology compendium.
(e) Other authoritative compendia as identified by the secretary of the United
States department of health and human services.
2. Medical literature may be accepted if all of the following apply:
(a) At least two articles from major peer reviewed professional medical journals
have recognized, based on scientific or medical criteria, the drug's safety and
effectiveness for treatment of the indication for which the drug has been prescribed.
(b) No article from a major peer reviewed professional medical journal has
concluded, based on scientific or medical criteria, that the drug is unsafe or
ineffective or that the drug's safety and effectiveness cannot be determined for the
treatment of the indication for which the drug has been prescribed.
(c) The literature meets the uniform requirements for manuscripts submitted to
biomedical journals established by the international committee of medical journal editors
or is published in a journal specified by the United States department of health and
human services as acceptable peer reviewed medical literature pursuant to section
186(t)(2)(B) of the social security act (42 United States Code section 1395x(t)(2)(B)).
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