CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Anticancer Medication — Orally Administered Anticancer Medication Cost-Sharing Parity

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.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAnticancer Medication — Orally Administered Anticancer Medication Cost-Sharing Parity

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2014

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility with the provider call center and refer to the member's subscriber agreement, benefit booklet, or employer agreement for applicable coverage details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2014Policy effective date

04/16/2020Last updated

requiredCost-sharing parity

RIGoverning statute

Coverage Criteria — Oral Anticancer Medication Parity

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Coverage parity for oral anticancer medications

Covered when ALL of the following are met

statutory and member benefit conditions: 1) Member has commercial coverage offering both medical and prescription drug benefits administered by Blue Cross & Blue Shield of Rhode Island (BCBSRI); 2) The plan provides coverage for intravenously administered anticancer medication under the medical benefit; 3) The prescribed orally administered anticancer medication is used to kill or slow the growth of cancerous cells; and 4) The pharmacy benefit provides coverage with cost-sharing no less favorable than the comparable intravenously administered or injected anticancer medication covered under the member's medical benefit.

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.

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.

Note

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.

Denial Risk

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

Billing Rule

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

Orally administered anticancer medication — RIGL § 27-20-67

Statutory definitionPrescribed oral medications used to kill or slow the growth of cancerous cells (RIGL § 27-20-67).

Scope of applicabilityApplies to individual or group hospital or medical expense insurance policies or plans delivered, issued for delivery, or renewed in Rhode Island on or after January 1, 2014 that offer both medical and prescription drug coverage and provide coverage for intravenously administered anticancer medication.

Parity requirementCoverage for orally administered anticancer medications must be provided on a basis no less favorable than intravenously administered or injected cancer medications covered as medical benefits.

Cost-sharing restrictionAn increase in patient cost sharing for anticancer medications shall not be allowed to achieve compliance; the statute does not impose any form of cap on cost-sharing.

Exempt product typesDoes not apply to: 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.

Revision History

2014-01-01effective_date

Policy became effective to implement RIGL § 27-20-67 covering orally administered anticancer medications for commercial members with both medical and prescription drug benefits.

2016-04-16last_review

Policy last updated/reviewed as indicated in document metadata.

2020-04-16last_updatedLatest

Policy most recently updated (policy last updated date shown in document metadata).