"Advanced metastatic cancer" is a cancer that has spread from the original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.
Step therapy is a form of prior authorization whereby health carriers 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. If the patient fails to respond to the drug or experiences an adverse effect then 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 not on the formulary.
This process may not unreasonably restrict an enrollee's access to non-formulary or alternative medicines for conditions 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.
Beginning in 2025 Medicaid and health plans, including those offered to public employees, that provide coverage for advanced metastatic cancer and associated conditions may not require, before the plan or Medicaid provides coverage of a prescription drug for the treatment of advanced metastatic cancer or an associated condition, the enrollee fail to successfully respond to a different drug or prove a history of failure of a different drug.
This requirement applies only to a drug the use of which is: