1Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2act relating to insurance; amending, revising, and
3consolidating the law providing for the incorporation of
4insurance companies, and the regulation, supervision, and
5protection of home and foreign insurance companies, Lloyds
6associations, reciprocal and inter-insurance exchanges, and
7fire insurance rating bureaus, and the regulation and
8supervision of insurance carried by such companies,
9associations, and exchanges, including insurance carried by
10the State Workmen's Insurance Fund; providing penalties; and
11repealing existing laws," in casualty insurance, providing
12for pharmaceutical coverage for oral anticancer medications.

13The General Assembly finds and declares as follows:

14(1) Cancer treatment through chemotherapy has changed
15over time. Traditional anticancer medications are primarily
16administered intravenously. Intravenous chemotherapy tends to
17attack both cancerous and healthy cells alike.

18(2) More recently, there has been an increase in the
19development of orally administered anticancer medications
20that target only cancer cells and have fewer side effects

1than intravenous chemotherapy. Orally administered anticancer
2medications are also more convenient for patients and their
3caregivers and often allow patients to reenter the work force
4with minimal time lost for cancer care.

5(3) Improvements in cancer treatment are contributing to
6increased survival rates across all forms of cancer and
7decreased side effects and allow patients to continue to
8participate in most life activities.

9(4) Research has found that more than 25% of all
10anticancer agents currently in development are planned as
11oral medications. In early trials many of these new oral
12medications have shown significant clinical advantages over
13traditional intravenous and injected forms of cancer
14medications.

15(5) Intravenous anticancer medications are typically
16covered under a health plan's medical benefit, often
17requiring patients to pay a minimal, fixed copayment or pay
18no cost for the medication.

19(6) Orally administered anticancer medications are
20covered under a health plan's pharmacy benefit. Under the
21pharmacy benefit, orally administered anticancer medications
22are placed on the highest (specialty) tier of a health plan's
23cost-sharing system.

24(7) Typically, patients who receive orally administered
25anticancer medications must pay coinsurance rates of 20% to
2630% and, at times, rates as high as 50% in a specialty tier,
27resulting in extremely high and unmanageable out-of-pocket
28costs. These costs create an enormous barrier for patients to
29access orally administered anticancer medications prescribed
30for their treatment.

1(8) Increases in out-of-pocket costs of orally
2administered anticancer medications are associated with a
3corresponding decrease in adherence to treatment, further
4risking patient health and making treatment longer, more
5expensive and less effective.

6(9) It is estimated that 10% of cancer patients fail to
7fill their initial prescriptions for orally administered
8anticancer medications due to high out-of-pocket costs, and
925% of cancer patients delay initiating an alternative
10treatment. Further, research demonstrates that patients
11reduce their recommended doses of orally administered
12anticancer medications to avoid paying for medication
13refills. These behaviors negatively impact the effectiveness
14of orally administered anticancer medications.

15(10) The disparity in out-of-pocket costs negatively
16impacts patient adherence to their medication regimens and
17forces physicians to make decisions based on health plan
18benefit design rather than the most effective treatment for a
19patient.

20(11) An increasing number of cancer patients are
21reporting that they cannot afford the out-of-pocket cost for
22orally administered anticancer medication, yet need the
23medication as part of their prescribed treatment.

24(12) For many cancer patients, no intravenous
25chemotherapy substitute exists for their prescribed oral
26anticancer medication.

27The General Assembly of the Commonwealth of Pennsylvania
28hereby enacts as follows:

29Section 1. The act of May 17, 1921 (P.L.682, No.284), known
30as The Insurance Company Law of 1921, is amended by adding a

1section to read:

2Section 631.1. Pharmaceutical Coverage for Oral Anticancer
3Medications.--(a) Whenever an individual or group health,
4sickness or accident insurance policy or subscriber contract or
5certificate issued by any entity subject to 40 Pa.C.S. Ch. 61
6(relating to hospital plan corporations) or 63 (relating to
7professional health services plan corporations) or this act
8provides pharmaceutical coverage that includes coverage for
9cancer chemotherapy or anticancer medications which have been
10approved by the United States Food and Drug Administration for
11general use in the treatment of cancer, the policy shall not
12place orally administered anticancer medications on a specialty
13tier or charge a coinsurance payment for orally administered
14anticancer medications. The prohibition of coinsurance payments
15applies to charging a percentage of the cost of the medication
16or a flat-fee cost that is specific to anticancer medication,
17but does not include charging the minimal copayment that is
18usual for covered prescription medications not on a specialty
19tier.

20(b) Nothing in this section shall serve to diminish the
21benefits of any insured or subscriber in effect on the effective
22date of this section, nor prevent the offering or acceptance of
23benefits which exceed the minimum benefits required by this
24section.

25(c) This section shall apply to those insurance policies,
26subscriber contracts or certificates issued or entered into or
27renewed on or after the effective date of this section.

28(d) As used in this section:

29"Anticancer medication" means a drug or <-biologic biological
30product that is used to kill, slow or prevent the growth of

1cancerous cells.

2"Specialty tier" means a formulary category for a
3prescription drug that meets one or more of the following
4criteria:

5(1) A high-cost medication that is used to treat and is
6prescribed for a person with a complex, chronic or rare medical
7condition.

8(2) The drug is not typically available at community retail
9pharmacies.

10(3) The drug requires special handling, storage or has
11distribution or inventory limitations.

12(4) The drug has a complex dosing regimen or requires
13special administration.

14(5) The drug is considered to have limited distribution by
15the United States Food and Drug Administration.

16(6) The drug requires complex and extended patient education
17or counseling, intensive monitoring or clinical oversight.

18(7) The drug has significant side effects or risk profile.

19Section 2. This act shall take effect immediately.