Introduced by Senator Leddy of Chittenden District and Senator White of Windham District
Subject: Health; insurance; prescription drugs; off-label use
Statement of purpose: This bill proposes to require state‑regulated health insurers to provide coverage for the off-label use of prescription drugs for cancer.
AN ACT RELATING TO OFF-LABEL USE OF PRESCRIPTION DRUGS FOR CANCER
It is hereby enacted by the General Assembly of the State of Vermont:
Sec. 1. 8 V.S.A. chapter 107, subchapter 9 is added to read:
Subchapter 9. Off-Label Use of Prescription Drugs for Cancer
§ 4100e. REQUIRED COVERAGE FOR OFF-LABEL USE
(a) A health insurance plan that provides coverage for prescription drugs shall provide coverage for off-label use in accordance with the following:
(1) A health insurance plan contract may not exclude coverage for any drug used for the treatment of cancer for a medically accepted indication on grounds that the drug has not been approved by the federal Food and Drug Administration for that indication, provided the use of the drug is a medically accepted indication for the treatment of cancer.
(2) Coverage of a drug required by this section also includes medically necessary services associated with the administration of the drug.
(3) This section shall not be construed to require coverage for a drug when the federal Food and Drug Administration has determined its use to be contraindicated for treatment of the current indication.
(4) A drug use that is covered under subdivision (1) of this subsection may not be denied coverage based on a “medical necessity” requirement except for a reason unrelated to the legal status of the drug use.
(5) A health insurance plan contract that provides coverage of a drug as required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles, and exclusions to the same extent these provisions are applicable to coverage of all prescription drugs and are not inconsistent with the requirements of this section.
(b) As used in this section, the following terms have the following meanings:
(1) “Health insurance plan” means a health benefit plan offered, administered, or issued by a health insurer doing business in Vermont.
(2) “Health insurer” is defined by subdivision 9402(9) of Title 18. As used in this subchapter, the term includes the state of Vermont and any agent or instrumentality of the state that offers, administers, or provides financial support to state government. It does not include Medicaid, the Vermont health access plan, the VScript pharmaceutical assistance program, or any other public health care assistance program.
(3) “Medically accepted indication” includes any use of a drug that has been approved by the federal Food and Drug Administration and includes another use of the drug if that use is supported by one or more citations in the standard reference compendia or if the nonprofit hospital and medical service organization involved, based upon guidance provided by the federal Department of Health and Human Services Medicare program under 42 United States Code, section 1395x(t), determines that that use is medically accepted based on supportive clinical evidence in peer-reviewed medical literature.
(4) “Off-label use” means the prescription and use of drugs for medically accepted indications other than those stated in the labeling approved by the federal Food and Drug Administration.
(5) “Peer-reviewed medical literature” means scientific studies published in at least two articles from major peer-reviewed medical journals that present data supporting the proposed off-label use as generally safe and effective.
(6) “Standard reference compendia” means:
(A) The United States Pharmacopeia Drug Information or information published by its successor organization; or
(B) The American Hospital Formulary Service Drug Information or information published by its successor organization.
Sec. 2. APPLICATION
Sec. 1 of this act shall apply to all health insurance plans issued or offered on and after July 1, 2006 and to all other health insurance plans on and after July 1, 2006 upon renewal or their anniversary date, whichever is sooner, but in no event later than June 30, 2007.
The Vermont General Assembly
115 State Street