Insurance Coverage for Eligible Patients

(A) Health care providers, benefits managers and insurers shall work cooperatively with patients with metastatic breast cancer to identify appropriate clinical trials involving the use of bone marrow transplants and provide coverage for bone marrow transplantation, in accordance with the eligibility criteria specified in 105 CMR 240.000. Health care providers or insurers specified in 105 CMR 240.003 who make treatment available through a network of participating providers may use the network to provide bone marrow transplants, in accordance with the requirements of 105 CMR 240.000. If bone marrow transplantation is not available through the network, the health care provider or insurer may arrange and shall provide coverage for a bone marrow transplant meeting the requirements of 105 CMR 240.000. (B) With respect to patients who have been diagnosed with breast cancer that has progressed to metastatic disease, the health care providers and insurers specified in 105 CMR 240.003 shall: (1) permit referral to and participation in clinical trials when an oncologist recommends participation on the grounds that the proposed procedure shows promise as a useful treatment for that patient, and the proposed procedure is likely to be at least as effective as conventional treatment for that patient; and (2) provide coverage for a bone marrow transplant, in accordance with 105 CMR 240.005(A), if the patient meets the eligibility criteria for enrollment into a clinical trial meeting the requirements of 105 CMR 240.006, even if the patient is not formally enrolled in that clinical trial; (3) provide coverage for a bone marrow transplant to the extent that benefits generally are provided for other medical procedures.