Senate File 197 - Introduced SENATE FILE 197 BY SWEENEY A BILL FOR An Act relating to insurance coverage for prescription drugs 1 used in the treatment of metastatic cancer and associated 2 conditions. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 2512XS (1) 91 nls/ko
S.F. 197 Section 1. NEW SECTION . 514C.24A Prescription drugs 1 metastatic cancer and associated conditions. 2 1. As used in this section, unless the context otherwise 3 requires: 4 a. Associated conditions means symptoms or side effects 5 associated with metastatic cancer, or with the health care 6 services for metastatic cancer provided by a covered persons 7 health care professional and which in the judgment of the 8 covered persons health professional jeopardizes the health of 9 the covered person. 10 b. Covered person means a policyholder, subscriber, or 11 other person participating in a policy, contract, or plan that 12 provides for third-party payment or prepayment of health or 13 medical expenses that provides coverage for prescription drugs. 14 c. Health care professional means the same as defined in 15 section 514J.102. 16 d. Health care services means services for the diagnosis, 17 prevention, treatment, cure, or relief of a health condition, 18 illness, injury, or disease. 19 e. Metastatic cancer means cancer that has spread from 20 the primary or original site of the cancer to tissue, lymph 21 nodes, or other parts of the body. Metastatic cancer may also 22 be referred to as advanced cancer or stage 4 cancer. 23 f. Prescription cancer drug means a prescription drug that 24 is used for the treatment of metastatic cancer or associated 25 conditions. 26 g. Prescription drug means a prescription drug that has 27 been prescribed as medically necessary by a covered persons 28 health care professional. 29 h. Step therapy protocol means the same as defined in 30 section 514F.7. 31 2. a. Notwithstanding the uniformity of treatment 32 requirements of section 514C.6, a policy, contract, or plan 33 providing for third-party payment or prepayment of health or 34 medical expenses that provides coverage for prescription drugs 35 -1- LSB 2512XS (1) 91 nls/ko 1/ 4
S.F. 197 shall provide coverage for prescription cancer drugs. 1 b. Notwithstanding section 514F.7, the policy, contract, or 2 plan shall provide coverage, without imposing a step therapy 3 protocol, for a prescription cancer drug that meets all of the 4 following requirements: 5 (1) The use of the prescription cancer drug is in accordance 6 with the medical standards of care for metastatic cancer or 7 associated conditions. 8 (2) The use of the prescription cancer drug for metastatic 9 cancer and associated conditions is supported by peer-reviewed, 10 evidence-based literature. 11 (3) The prescription cancer drug has been approved by the 12 United States food and drug administration. 13 3. a. This section applies to the following classes of 14 third-party payment provider contracts, policies, or plans 15 delivered, issued for delivery, continued, or renewed in this 16 state on or after January 1, 2026: 17 (1) Individual or group accident and sickness insurance 18 providing coverage on an expense-incurred basis. 19 (2) An individual or group hospital or medical service 20 contract issued pursuant to chapter 509, 514, or 514A. 21 (3) An individual or group health maintenance organization 22 contract regulated under chapter 514B. 23 (4) A plan established for public employees pursuant to 24 chapter 509A. 25 b. This section shall not apply to accident-only, specified 26 disease, short-term hospital or medical, hospital confinement 27 indemnity, credit, dental, vision, Medicare supplement, 28 long-term care, basic hospital and medical-surgical expense 29 coverage as defined by the commissioner of insurance, 30 disability income insurance coverage, coverage issued as a 31 supplement to liability insurance, workers compensation or 32 similar insurance, or automobile medical payment insurance. 33 4. The commissioner of insurance may adopt rules pursuant to 34 chapter 17A to administer this section. 35 -2- LSB 2512XS (1) 91 nls/ko 2/ 4
S.F. 197 EXPLANATION 1 The inclusion of this explanation does not constitute agreement with 2 the explanations substance by the members of the general assembly. 3 This bill relates to insurance coverage for prescription 4 drugs used in the treatment of metastatic cancer. 5 The bill requires policies, contracts, or plans providing 6 for third-party payment or prepayment of health or medical 7 expenses that provide coverage for prescription drugs to 8 provide coverage for prescription cancer drugs. Prescription 9 cancer drug is defined in the bill as a prescription drug that 10 is used to treat metastatic cancer or associated conditions. 11 Metastatic cancer is also defined in the bill. 12 The policy, contract, or plan is required to provide 13 coverage, without imposing a step therapy protocol, for a 14 prescription cancer drug that has been approved by the United 15 States food and drug administration, the use of which is in 16 accordance with medical standards of care for metastatic cancer 17 and associated conditions, and the use of which is supported 18 by peer-reviewed, evidence-based literature. Associated 19 conditions is defined in the bill. Step therapy protocol is 20 defined in the bill as a protocol or program that establishes a 21 specific sequence in which prescription drugs for a specified 22 medical condition and medically appropriate for a particular 23 covered person are covered under a pharmacy or medical benefit 24 by a health carrier, a health benefit plan, or a utilization 25 review organization, including self-administered drugs and 26 drugs administered by a health care professional. 27 The bill applies to the third-party payment providers 28 enumerated in the bill. The bill specifies the types of 29 specialized health-related insurance which are not subject to 30 the coverage requirements of the bill. 31 The commissioner of insurance may adopt rules to administer 32 the requirements of the bill. 33 The provisions of the bill are applicable to third-party 34 payment provider contracts, policies, or plans delivered, 35 -3- LSB 2512XS (1) 91 nls/ko 3/ 4
S.F. 197 issued for delivery, continued, or renewed in this state on or 1 after January 1, 2026. 2 -4- LSB 2512XS (1) 91 nls/ko 4/ 4