AN ACT Relating to restricting the use of step therapy by public and private insurers for drugs used in mental health treatment; adding a new section to chapter 48.43 RCW; adding a new section to chapter 41.05 RCW; and adding a new section to chapter 74.09 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1.  A new section is added to chapter 48.43 RCW to read as follows:

(1) Beginning July 1, 2018, each carrier offering or renewing a health benefit plan may require step therapy for medications necessary for the treatment of mental illness only as follows:

(a) The carrier may require a first attempt treatment using one particular drug covered by the carrier unless the patient's prescribing practitioner demonstrates that the patient has already tried and failed on the carrier's first attempt treatment drug or a drug in the same pharmacologic class, in which case, the carrier must provide immediate coverage for the drug prescribed by the practitioner.

(b) Following a patient's use of the first attempt drug, the carrier must provide immediate coverage for the drug prescribed by the patient's prescribing practitioner if the patient's prescribing practitioner determines that the first attempt drug:

(i) Must be discontinued due to lack of efficacy, diminished effect, or an adverse event;

(ii) Is contraindicated or will likely cause an adverse reaction in, or physical or mental harm to, the patient;

(iii) Is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the first attempt prescription drug; or

(iv) Is not in the best interest of the patient, based on medical necessity.

(2) This section does not prohibit generic substitution.

(3) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.

(a) "Mental health medications" means stimulants, antidepressants, antipsychotics, mood stabilizers, and antianxiety agents used in the treatment of mental health disorders and conditions.

(b) "Step therapy" means a program establishing the specific sequence in which medically appropriate prescription drugs, including self-administered and physician-administered drugs, for a specified medical condition are covered as a pharmacy or medical benefit by a carrier. "Step therapy" does not include substituting a generic drug for the drug prescribed by the prescribing practitioner.

NEW SECTION.  Sec. 2.  A new section is added to chapter 41.05 RCW to read as follows:

(1) Beginning July 1, 2018, the health care authority may require step therapy for medications necessary for the treatment of mental illness only as follows:

(a) The authority may require a first attempt treatment using one particular drug covered by the authority unless the patient's prescribing practitioner demonstrates that the patient has already tried and failed on the authority's first attempt treatment drug or a drug in the same pharmacologic class, in which case, the authority must provide immediate coverage for the drug prescribed by the practitioner.

(b) Following a patient's use of the first attempt drug, the authority must provide immediate coverage for the drug prescribed by the patient's prescribing practitioner if the patient's prescribing practitioner determines that the first attempt drug:

(i) Must be discontinued due to lack of efficacy, diminished effect, or an adverse event;

(ii) Is contraindicated or will likely cause an adverse reaction in, or physical or mental harm to, the patient;

(iii) Is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the first attempt prescription drug; or

(iv) Is not in the best interest of the patient, based on medical necessity.

(2) This section does not prohibit generic substitution.

(3) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.

(a) "Mental health medications" means stimulants, antidepressants, antipsychotics, mood stabilizers, and antianxiety agents used in the treatment of mental health disorders and conditions.

(b) "Step therapy" means a program establishing the specific sequence in which medically appropriate prescription drugs, including self-administered and physician-administered drugs, for a specified medical condition are covered as a pharmacy or medical benefit by a carrier. "Step therapy" does not include substituting a generic drug for the drug prescribed by the prescribing practitioner.

NEW SECTION.  Sec. 3.  A new section is added to chapter 74.09 RCW to read as follows:

(1) Beginning July 1, 2018, the health care authority may require step therapy for medications necessary for the treatment of mental illness only as follows:

(a) The authority may require a first attempt treatment using one particular drug covered by the authority unless the patient's prescribing practitioner demonstrates that the patient has already tried and failed on the authority's first attempt treatment drug or a drug in the same pharmacologic class, in which case, the authority must provide immediate coverage for the drug prescribed by the practitioner.

(b) Following a patient's use of the first attempt drug, the authority must provide immediate coverage for the drug prescribed by the patient's prescribing practitioner if the patient's prescribing practitioner determines that the first attempt drug:

(i) Must be discontinued due to lack of efficacy, diminished effect, or an adverse event;

(ii) Is contraindicated or will likely cause an adverse reaction in, or physical or mental harm to, the patient;

(iii) Is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the first attempt prescription drug; or

(iv) Is not in the best interest of the patient, based on medical necessity.

(2) This section does not prohibit generic substitution.

(3) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.

(a) "Mental health medications" means stimulants, antidepressants, antipsychotics, mood stabilizers, and antianxiety agents used in the treatment of mental health disorders and conditions.

(b) "Step therapy" means a program establishing the specific sequence in which medically appropriate prescription drugs, including self-administered and physician-administered drugs, for a specified medical condition are covered as a pharmacy or medical benefit by a carrier. "Step therapy" does not include substituting a generic drug for the drug prescribed by the prescribing practitioner.

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