Mandated Health Benefits – Oral Chemotherapy Medication | PA Benefit Advisors

On July 8, 2016, Pennsylvania Governor Tom Wolfe signed legislation (H.B. 60) regarding health insurance coverage for oral chemotherapy medications.

Pursuant to the bill, whenever a health insurance policy provides coverage that includes coverage for intravenously administered or injected chemotherapy medications which have been approved by the U.S. Food and Drug Administration for general use in the treatment of cancer, the policy may not provide coverage or impose cost sharing for a prescribed, orally administered chemotherapy medication on a less favorable basis than the coverage it provides or cost sharing it imposes for intravenously administered or injected chemotherapy medications.

A health insurance policy may not increase cost sharing for chemotherapy medications to avoid compliance with the above. A health insurance policy may increase cost sharing for chemotherapy medications if an increase is applied generally to other medical or pharmaceutical benefits administered in a similar health care setting under the contract.

The prohibitions listed above do not preclude a health insurance policy from requiring an enrollee to obtain prior authorization before orally administered chemotherapy medication is dispensed to the enrollee. As part of prior authorization, an insurer may consider the medical necessity and cost of oral chemotherapy medications compared with intravenously administered or inject chemotherapy medication.

The law applies to a high deductible health plan only after the covered person’s deductible has been satisfied for the year.

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Fairmount Benefits Company

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Radnor, PA 19087

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