Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
(a)
“Cost sharing” means the enrollee‘s maximum out-of-pocket costs as defined by the health benefit plan.
(b)
“Health insurer” is as defined in Subsection 31A-22-634(1).
(c)
“Intravenously administered chemotherapy” means a physician-prescribed cancer treatment that is used to kill or slow the growth of cancer cells, that is administered through injection directly into the patient’s circulatory system by a physician, physician assistant, nurse practitioner, nurse, or other medical personnel under the supervision of a physician, and in a hospital, medical office, or other clinical setting.
(d)
“Oral chemotherapy” means a United States Food and Drug Administration-approved, physician-prescribed cancer treatment that is used to kill or slow the growth of cancer cells, that is taken orally in the form of a tablet or capsule, and may be administered in a hospital, medical office, or other clinical setting or may be delivered to the patient for self-administration under the direction or supervision of a physician outside of a hospital, medical office, or other clinical setting.
(2)
This section applies to health benefit plans renewed or entered into on or after October 1, 2013.
(3)
A health benefit plan that covers prescribed oral chemotherapy and intravenously administered chemotherapy shall:
(a)
except as provided in Subsection (3)(b), ensure that the cost sharing applied to the covered oral chemotherapy is no more restrictive than the cost sharing applied to the covered intravenously administered chemotherapy; or
(b)
if the cost sharing for oral chemotherapy is more restrictive than the cost sharing for intravenous chemotherapy, the health benefit plan may not apply cost sharing for the oral chemotherapy that exceeds $300 per filled prescription.
(4)
(a)
A health insurer shall not increase the cost sharing for intravenously administered chemotherapy for the purpose of achieving compliance with this section.
