A. Evaluation of the Analysis to Eliminate Step Therapy for Metastatic Cancer Side Effect Treatments. The Contractor shall utilize its health care actuaries’ knowledge and experience, proprietary databases, in-house data, carrier surveys, and other externally available data sources to complete this actuarial evaluation, that includes the following: 1. A social evaluation including: a) the extent to which the coverage and reimbursement requirement (or “the service”) is generally utilized by a significant portion of the population; b) the extent to which the insurance coverage is already generally available; c) the extent to which the lack of coverage results in individuals avoiding necessary health care treatments; d) the extent to which the lack of coverage results in unreasonable financial hardship; e) the level of public demand for the service; f) the level of public demand for insurance coverage of the service; and g) the extent to which the service is covered by self–funded employer groups of employers in the State who employ at least 500 employees. 2. A medical evaluation including: a) the extent to which the service is generally recognized by the medical community as being effective and efficacious in the treatment of patients; b) the extent to which the service is generally recognized by the medical community as demonstrated by a review of scientific and peer review literature; and c) the extent to which the service is generally available and utilized by treating physicians.
