TO: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts (BCBSMA), Health Maintenance Organizations (HMOs)
FROM: Linda Ruthardt, Commissioner of Insurance
DATE: May 23, 1995
RE: Coverage for drugs used for HIV/AIDS treatment

Several laws have been enacted which mandate certain drug coverage for the treatment of HIV/AIDS: St. 1994, c. 60, §§ 142, 144, 146, and 149 which added G.L. c. 175, §§ 47O and 47P; G.L. c. 176A, § 8O; G.L. c. 176B, § 4P and; G.L. c. 176G, § 4G. This mandate is effective for policies, certificates, evidences of coverage and contracts that provide coverage for prescription drugs which are issued or renewed on or after July 1, 1994 as set forth in the above noted statutes.

The mandate prohibits commercial health insurers, BCBSMA and HMOs from excluding coverage for drugs used for the treatment of' HIV/AIDS on the grounds that the off-label use of the drug has not been approved by the federal Food and Drug Administration for that indication if the drug is recognized for treatment of such indication in one of the standard reference compendia (i.e., the United States Pharmacopia Drug Information, the American Medical Association Drug Evaluations or the American Hospital Formulary Service Drug Information) or in the medical literature (i.e., published scientific studies published in any peer-reviewed national professional journal) or by the Commissioner pursuant to an advisory panel established under G.L. c. 175, § 47P. Any coverage of a drug required by the law shall also include medically necessary services associated with the administration of the drug.

Please refer to the laws cited above for a complete description of the requirements. For this mandate, the Division requires that coverage of the benefits be provided at either the same level or at a greater level as for any other prescription drug. All affected policies, certificates, evidences of coverage and contracts must be amended according to the above noted laws. Also, policyholders, subscribers and members must be notified of the new benefits and their effective dates.

Any questions regarding this bulletin should be directed to the Health Policy Unit at (617) 521-7349.