500.3406ff Financial parity for orally administered, intravenously administered and injected antineoplastic (anticancer) medications.
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500.3406ff Financial parity for orally administered, intravenously administered and injected antineoplastic (anticancer) medications.
Sec. 3406ff.
(1)A health insurance policy delivered, issued for delivery, or renewed in this state that provides coverage for prescribed orally administered antineoplastic medications and intravenously administered or injected antineoplastic medications must ensure either of the following:
(a)That financial requirements applicable to prescribed orally administered antineoplastic medications are not more restrictive than the financial requirements that apply to intravenously administered or injected antineoplastic medications that are covered by the health insurance policy.
(b)That the co-pay or coinsurance for orally administered antineoplastic medication does not exceed $250.00 per 30-day supply. Beginning January 1, 2026, and each January 1 after that date, the department shall adjust the financial requirement described in this subdivision by an amount determined by the state treasurer that reflects the cumulative annual change in the prescription drug index of the medical care component of the United States Consumer Price Index.
(2)An insurer cannot achieve compliance with this section by increasing cost-sharing requirements, reclassifying benefits with respect to antineoplastic medications, or imposing more restrictive treatment limitations on prescribed orally administered antineoplastic medications or intravenously administered or injected antineoplastic medications covered under a health insurance policy described in subsection (1).
(3)This section does not prohibit an insurer from applying utilization management techniques, including prior authorization, step therapy, limits on quantity dispensed, and days' supply per fill for any administered antineoplastic medication.
(4)As used in this section:
(a)"Antineoplastic medication" means a medication used to kill, slow, or prevent the growth of cancerous cells.
(b)"Cost-sharing requirement" means deductibles, copayments, coinsurance, out-of-pocket expenses, aggregate lifetime limits, and annual limits.
(c)"Treatment limitation" means limits on the frequency of treatment, days of coverage, or other similar limits on the scope or duration of treatment. Treatment limitation does not include the application of utilization management techniques described in subsection (3).
History: Add. 2023, Act 170 , Eff. Feb. 13, 2024
Compiler's Notes: Enacting section 1 of Act 170 of 2023 provides:"Enacting section 1. This amendatory act applies to health insurance policies delivered, issued for delivery, or renewed in this state after December 31, 2025."
Popular Name: Act 218