Nevada Revised Statutes 695C.17333 – Plan covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Health maintenance organization required to allow enrollee or attending practitioner to apply for ex…
1. A health maintenance organization that offers or issues a health care plan which provides coverage of a prescription drug for the treatment of cancer or any symptom of cancer that is part of a step therapy protocol shall allow an enrollee who has been diagnosed with stage 3 or 4 cancer or the attending practitioner of the enrollee to apply for an exemption from the step therapy protocol. The application process for such an exemption must:
Terms Used In Nevada Revised Statutes 695C.17333
- Enrollee: means a natural person who has been voluntarily enrolled in a health care plan. See Nevada Revised Statutes 695C.030
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health care plan: means any arrangement whereby any person undertakes to provide, arrange for, pay for or reimburse any part of the cost of any health care services and at least part of the arrangement consists of arranging for or the provision of health care services paid for by or on behalf of the enrollee on a periodic prepaid basis. See Nevada Revised Statutes 695C.030
- Health maintenance organization: means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. See Nevada Revised Statutes 695C.030
- person: means a natural person, any form of business or social organization and any other nongovernmental legal entity including, but not limited to, a corporation, partnership, association, trust or unincorporated organization. See Nevada Revised Statutes 0.039
- physician: means a person who engages in the practice of medicine, including osteopathy and homeopathy. See Nevada Revised Statutes 0.040
(a) Allow the enrollee or attending practitioner, or a designated advocate for the enrollee or attending practitioner, to present to the health maintenance organization the clinical rationale for the exemption and any relevant medical information.
(b) Clearly prescribe the information and supporting documentation that must be submitted with the application, the criteria that will be used to evaluate the request and the conditions under which an expedited determination pursuant to subsection 4 is warranted.
(c) Require the review of each application by at least one physician, registered nurse or pharmacist.
2. The information and supporting documentation required pursuant to paragraph (b) of subsection 1:
(a) May include, without limitation:
(1) The medical history or other health records of the enrollee demonstrating that the enrollee has:
(I) Tried other drugs included in the pharmacological class of drugs for which the exemption is requested without success; or
(II) Taken the requested drug for a clinically appropriate amount of time to establish stability in relation to the cancer and the guidelines of the prescribing practitioner; and
(2) Any other relevant clinical information.
(b) Must not include any information or supporting documentation that is not necessary to make a determination about the application.
3. Except as otherwise provided in subsection 4, a health maintenance organization that receives an application for an exemption pursuant to subsection 1 shall:
(a) Make a determination concerning the application if the application is complete or request additional information or documentation necessary to complete the application not later than 72 hours after receiving the application; and
(b) If it requests additional information or documentation, make a determination concerning the application not later than 72 hours after receiving the requested information or documentation.
4. If, in the opinion of the attending practitioner, a step therapy protocol may seriously jeopardize the life or health of the enrollee, a health maintenance organization that receives an application for an exemption pursuant to subsection 1 must make a determination concerning the application as expeditiously as necessary to avoid serious jeopardy to the life or health of the enrollee.
5. A health maintenance organization shall disclose to the enrollee or attending practitioner who submits an application for an exemption from a step therapy protocol pursuant to subsection 1 the qualifications of each person who will review the application.
6. A health maintenance organization must grant an exemption from a step therapy protocol in response to an application submitted pursuant to subsection 1 if:
(a) Any treatment otherwise required under the step therapy or any drug in the same pharmacological class or having the same mechanism of action as the drug for which the exemption is requested has not been effective at treating the cancer or symptom of the enrollee when prescribed in accordance with clinical indications, clinical guidelines or other peer-reviewed evidence;
(b) Delay of effective treatment would have severe or irreversible consequences for the enrollee and the treatment otherwise required under the step therapy is not reasonably expected to be effective based on the physical or mental characteristics of the enrollee and the known characteristics of the treatment;
(c) Each treatment otherwise required under the step therapy:
(1) Is contraindicated for the enrollee or has caused or is likely, based on peer-reviewed clinical evidence, to cause an adverse reaction or other physical harm to the enrollee; or
(2) Has prevented or is likely to prevent the enrollee from performing the responsibilities of his or her occupation or engaging in activities of daily living, as defined in 42 C.F.R. § 441.505;
(d) The condition of the enrollee is stable while being treated with the prescription drug for which the exemption is requested and the enrollee has previously received approval for coverage of that drug; or
(e) Any other condition for which such an exemption is required by regulation of the Commissioner is met.
7. If a health maintenance organization approves an application for an exemption from a step therapy protocol pursuant to this section, the health maintenance organization must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable health care plan. The health maintenance organization may initially limit the coverage to a 1-week supply of the drug for which the exemption is granted. If the attending practitioner determines after 1 week that the drug is effective at treating the cancer or symptom for which it was prescribed, the health maintenance organization must continue to cover the drug for as long as it is necessary to treat the enrollee for the cancer or symptom. The health maintenance organization may conduct a review not more frequently than once each quarter to determine, in accordance with available medical evidence, whether the drug remains necessary to treat the enrollee for the cancer or symptom. The health maintenance organization shall provide a report of the review to the enrollee.
8. A health maintenance organization shall post in an easily accessible location on an Internet website maintained by the health maintenance organization a form for requesting an exemption pursuant to this section.
9. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by this section, and any provision of the health care plan that conflicts with this section is void.
10. As used in this section, ‘attending practitioner’ means the practitioner, as defined in NRS 639.0125, who has primary responsibility for the treatment of the cancer or any symptom of such cancer of an enrollee.