Prevention and Treatment of Cancer

V.S.A. tit. 8, ch. 107, subch. 11

in effect

8 V.S.A. § 4095a Colorectal cancer screening

4095a. Colorectal cancer screening (a) As used in this section, “colonoscopy” means a procedure that enables a health care professional to examine visually the inside of a patient’s entire colon and includes the concurrent removal of polyps or biopsy, or both. (b) A health insurance plan shall provide coverage for colorectal cancer screening, including: (1) for a covered individual who is not at high risk for colorectal cancer, colorectal cancer screening examinations and laboratory tests in accordance with the most recently published recommendations established by the U.S. Preventive Services Task Force for average-risk individuals; and (2) for a covered individual who is at high risk for colorectal cancer, colorectal cancer screening examinations and laboratory tests as recommended by the treating health care professional. (c) For the purposes of subdivision (b)(2) of this section, an individual is at high risk for colorectal cancer if the individual has: (1) a family medical history of colorectal cancer or a genetic syndrome predisposing the individual to colorectal cancer; (2) a prior occurrence of colorectal cancer or precursor polyps; (3) a prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Crohn’s disease, or ulcerative colitis; or (4) other predisposing factors as determined by the individual’s treating health care professional. (d) Colorectal cancer screening services performed under contract with the insurer shall not be subject to any co-payment, deductible, coinsurance, or other cost-sharing requirement. In addition, a covered individual shall not be subject to any additional charge for any service associated with a procedure or test for colorectal cancer screening, which may include one or more of the following: (1) removal of tissue or other matter; (2) laboratory services; (3) health care professional services; (4) facility use; and (5) anesthesia. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4095b Mammography and other breast imaging services

4095b. Mammography and other breast imaging services (a)(1) A health insurance plan shall provide coverage for screening mammography and for other medically necessary breast imaging services upon recommendation of a health care professional as needed to detect the presence of breast cancer and other abnormalities of the breast or breast tissue. In addition, a health insurance plan shall provide coverage for screening by ultrasound or another appropriate imaging service for a covered individual for whom the results of a screening mammogram were inconclusive or who has dense breast tissue, or both. (2) Benefits provided shall cover the full cost of the mammography, ultrasound, and other breast imaging services and shall not be subject to any co-payment, deductible, coinsurance, or other cost-sharing requirement or additional charge, except to the extent that such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to 26 U.S.C. § 223. (b) This section shall apply only to procedures conducted by test facilities accredited by the American College of Radiologists. (c) As used in this section: (1) “Mammography” means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and digital detector. The term includes breast tomosynthesis. (2) “Other breast imaging services” means diagnostic mammography, ultrasound, and magnetic resonance imaging services that enable health care professionals to detect the presence or absence of breast cancer and other abnormalities affecting the breast or breast tissue. (3) “Screening” includes the mammography or ultrasound test procedure and a qualified health care professional’s interpretation of the results of the procedure, including additional views and interpretation as needed. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4095c Prostate cancer screenings

4095c. Prostate cancer screenings A health insurance plan shall provide coverage for prostate cancer screenings consistent with the recommendations of the Centers for Disease Control and Prevention or upon recommendation of the covered individual’s health care professional. Benefits provided shall be at least as favorable as coverage for other cancer screening procedures and subject to the same dollar limits, deductibles, and coinsurance factors within the provisions of the policy. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4095d Chemotherapy treatment and oral anticancer medications

4095d. Chemotherapy treatment and oral anticancer medications (a) A health insurance plan shall provide coverage for medically necessary growth cell stimulating factor injections taken as part of a prescribed chemotherapy regimen. (b) A health insurance plan shall provide coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells that is not less favorable on a financial basis than intravenously administered or injected anticancer medications covered under the covered individual’s plan. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4095e Clinical trials for cancer patients

4095e. Clinical trials for cancer patients (a) The Commissioner shall, after notice and hearing, adopt rules requiring that all health insurance plans issued in this State provide coverage for routine costs for covered individuals who participate in cancer clinical trials. (1) Any rules adopted under this section shall be limited to the coverage of routine costs for covered individuals who participate in a cancer clinical trial. (2) Any rules adopted under this section shall be restricted to approved cancer clinical trials conducted under the auspices of the following cancer care providers (cancer care providers): The University of Vermont Medical Center, the Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, and approved clinical trials administered by a hospital and its affiliated, qualified cancer care providers. (3) For participation in clinical trials located outside Vermont, coverage under this section shall be required only if the covered individual provides notice to the health insurance plan prior to participation in the clinical trial, and one or more of the following circumstances applies: (A) no clinical trial is available at the Vermont or New Hampshire cancer care providers described in subdivision (2) of this subsection (a); (B) the covered individual already has completed a clinical trial at one of the Vermont or New Hampshire cancer care providers described in subdivision (2) of this subsection (a) and the covered individual’s cancer care provider determines that a subsequent clinical trial related to the original diagnosis is available outside the health benefit plan’s network and that participation in that clinical trial would be in the best interests of the covered individual, even if a comparable clinical trial is available at that time at one or both of the Vermont or New Hampshire cancer care providers described in subdivision (2) of this subsection (a); or (C) the health insurance plan has already approved a referral of the covered individual to an out-of-network cancer care provider and an out-of-network clinical trial becomes available and the covered individual’s cancer care provider determines participation in that clinical trial would be in the best interests of the covered individual, even if a comparable clinical trial is available at one or both of the Vermont or New Hampshire cancer care providers described in subdivision (2) of this subsection (a). (4) If a covered individual participates in a clinical trial administered by a cancer care provider that is not in the health insurance plan’s provider network, the health insurance plan may require that routine follow-up care be provided within the health insurance plan’s network, unless the cancer care provider determines this would not be in the best interests of the covered individual. (b) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4095f Off-label use of prescription drugs for cancer

4095f. Off-label use of prescription drugs for cancer (a) As used in this section: (1) “Medical or scientific evidence” means one or more of the following sources: (A) peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; (B) peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health’s National Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline, and MEDLARS database Health Services Technology Assessment Research (HSTAR); (C) medical journals recognized by the Secretary of the U.S. Department of Health and Human Services under Section 1861(t)(2) of the Social Security Act; (D) the following standard reference compendia: the American Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluation, and the United States Pharmacopoeia-Drug Information; (E) findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including the Agency for Health Care Policy and Research, National Institutes of Health, National Cancer Institute, National Academy of Sciences, Centers for Medicare and Medicaid Services, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services; and (F) peer-reviewed abstracts accepted for presentation at major medical association meetings. (2) “Medically accepted indication” includes any use of a drug that has been approved by the U.S. Food and Drug Administration and includes another use of the drug if that use is prescribed by the covered individual’s health care professional and supported by medical or scientific evidence. (3) “Off-label use” means the prescription and use of drugs for medically accepted indications other than those stated in the labeling approved by the U.S. Food and Drug Administration. (b) A health insurance plan shall provide coverage for off-label use in cancer treatment in accordance with the following: (1) A health insurance plan contract shall not exclude coverage for any drug used for the treatment of cancer on grounds that the drug has not been approved by the U.S. Food and Drug Administration, 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 U.S. 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 shall 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 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. (c) A determination by a health insurer that an off-label use of a prescription drug under this section is not a medically accepted indication supported by medical or scientific evidence is eligible for review under section 4063 of this title. (d) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

Source: Vermont General Assembly (legislature.vermont.gov)URL: https://legislature.vermont.gov/statutes/chapter/08/107Fetched: 10/21/2026