Anticancer Medication — Orally Administered Anticancer Medication Cost-Sharing Parity
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Defines coverage and cost-sharing parity for orally administered anticancer medications for commercial members of Blue Cross & Blue Shield of Rhode Island when both medical and pharmacy benefits are offered; aligns with Rhode Island law RIGL § 27-20-67.
No material clinical or coverage changes in this revision.
Coverage Criteria — Oral Anticancer Medication Parity
Coverage parity for oral anticancer medications
Covered when ALL of the following are met
Applies per RIGL § 27-20-67; does not apply to BlueCHiP for Medicare and certain limited benefit product types listed in statute (e.g., hospital confinement indemnity, disability income, accident only, long-term care, Medicare supplement, limited benefit health, specified disease indemnity, sickness or bodily injury or death by accident, and other limited benefit policies).
This policy does not apply to members covered under BlueCHiP for Medicare. It also excludes the limited product types specifically listed in RIGL § 27-20-67, including hospital confinement indemnity, disability income, accident only, long-term care, Medicare supplement, limited benefit health, specified disease indemnity, sickness or bodily injury or death by accident, and other limited benefit policies. Self-funded employer groups may elect whether to follow applicable state mandates, so coverage for those groups may vary.
Coding
| No codes listed |
Provider Actions and Operational Notes
Prior Authorization
Prior authorization is not applicable per the policy statement.
Step Therapy
No step therapy requirements specified in this policy. If a member's benefit design imposes step therapy requirements for orally administered anticancer medications, providers should follow the member-specific Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.
Verify Member Benefits
Providers should verify member-specific benefits and eligibility with the provider call center and refer to the member's subscriber agreement or Benefit Booklet for applicable coverage details.
Coverage Contingent on Member Benefit Design
Coverage is contingent on the member's specific benefit design. Denial may occur if benefits or coverage for orally administered anticancer medications are not available under the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.
Site of Care and Benefit Assignment
Pharmacy benefit — site of care not restricted
Coverage for orally administered anticancer medications is provided under the member's pharmacy benefit; this policy does not restrict site of care.
- Cost-sharing for oral anticancer medications must be no less favorable than the comparable intravenously administered or injected cancer medications under the member's medical benefit.
Background and Legal Basis
This policy implements Rhode Island law RIGL § 27-20-67, which requires that when a commercial product offers both medical and prescription drug coverage and covers intravenously administered anticancer medications under the medical benefit, the plan must also cover prescribed orally administered anticancer medications under the pharmacy benefit on a basis no less favorable than the comparable medical benefit for IV/injected cancer medications. The statute further specifies that plans may not increase patient cost sharing to achieve compliance and does not impose a cap on cost-sharing. This requirement is effective for policies delivered, issued, or renewed on or after January 1, 2014 and applies to applicable commercial products administered by BCBSRI.
Definitions
Revision History
Policy became effective to implement RIGL § 27-20-67 covering orally administered anticancer medications for commercial members with both medical and prescription drug benefits.
Policy last updated/reviewed as indicated in document metadata.
Policy most recently updated (policy last updated date shown in document metadata).
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