SENATE BILL REPORT

SB 5626

This analysis was prepared by non-partisan legislative staff for the use of legislative members in their deliberations. This analysis is not a part of the legislation nor does it constitute a statement of legislative intent.

Background: Step therapy is a form of prior authorization whereby health benefit plans approve a prescription drug or class of drugs for a medical condition based on cost-effectiveness and treatment best practices. Step therapy requires the patient to begin treatment with the approved drug and to fail to respond to the drug or have an adverse effect before coverage is allowed for another drug prescribed by the patient's health care provider.

In Washington, health carriers may design their prescription drug benefit plans to include cost control measures, including requiring preferred drug substitution in a given therapeutic class if the restriction is for a less expensive, equally therapeutic alternative product available to treat the condition. Carriers must also establish a process that a provider and an enrollee may use to request substitution for a prescribed therapy, drug, or medication that is not on the formulary. This process may not unreasonably restrict an enrollee's access to non-formulary or alternative medicines for conditions that are not responsive to treatment. Carriers must also have a process for an enrollee to request an expedited review based on exigent circumstances such as experiencing a health condition that may jeopardize the enrollee's life or when an enrollee is undergoing a current course of treatment using a non-formulary drug.

Metastasis is the process by which cancer cells spread through the body. Metastatic cancer is cancer that has spread through the body from it originating location and, for many types of cancers, are also called stage IV cancer. For example, breast cancer cells that have spread into the lung are called metastatic breast cancer and are treated as stage IV breast cancer, not as lung cancer. Metastatic cancer is difficult to treat, and the goal of many of these treatments is to stop or slow the growth of the cancer or to relieve the cancer's symptoms.