wa-law.org > bill > 2025-26 > SB 5916 > Engrossed Substitute
A health plan issued or renewed on or after January 1, 2027, and any health care benefit manager as defined in RCW 48.200.020 that is directly or indirectly contracted with the health plan, shall provide coverage for at least one nonopioid legend drug for the treatment or management of pain without prescription drug utilization management, including prior authorization or step therapy protocols.
For the purposes of this section, "nonopioid drug" means a drug or biological product that is indicated to produce analgesia without acting on the body's opioid receptors and that has been approved by the United States food and drug administration.
Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 48.200.300 through 48.200.320, 48.43.440, 48.43.845, 48.43.732, section 1 of this act, and chapter 48.49 RCW.
Beginning January 1, 2027, a managed care organization shall provide coverage for at least one nonopioid legend drug for the treatment or management of pain without prescription drug utilization management, including prior authorization or step therapy protocols.
The authority shall assure that any prescription drug practices that it applies to fee-for-service programs and managed care organizations under this chapter comply with the requirements of subsection (1) of this section.
For the purposes of this section:
"Nonopioid drug" means a drug or biological product that is indicated to produce analgesia without acting on the body's opioid receptors and that has been approved by the United States food and drug administration.
"Prior authorization" has the same meaning as in RCW 48.43.400.
"Step therapy protocol" has the same meaning as in RCW 48.43.400.
By January 1, 2027, the department shall develop and publish on its website an educational pamphlet regarding the use of nonopioid alternatives for the treatment of pain. At a minimum, the pamphlet must include:
Information on available nonopioid alternatives for the treatment of pain, including nonopioid medicinal drugs or drug products and nonpharmacological therapies; and
The advantages and disadvantages of the use of nonopioid alternatives.
The definitions in this section apply throughout this section and RCW 48.43.410 , 48.43.420, and section 1 of this act unless the context clearly requires otherwise.
"Clinical practice guidelines" means a systemically developed statement to assist decision making by health care providers and patients about appropriate health care for specific clinical circumstances and conditions.
"Clinical review criteria" means the written screening procedures, decision rules, medical protocols, and clinical practice guidelines used by a health carrier or prescription drug utilization management entity as an element in the evaluation of medical necessity and appropriateness of requested prescription drugs under a health plan.
"Emergency fill" means a limited dispensed amount of medication that allows time for the processing of prescription drug utilization management.
"Medically appropriate" means prescription drugs that under the applicable standard of care are appropriate: (a) To improve or preserve health, life, or function; (b) to slow the deterioration of health, life, or function; or (c) for the early screening, prevention, evaluation, diagnosis, or treatment of a disease, condition, illness, or injury.
"Prescription drug utilization management" means a set of formal techniques used by a health carrier or prescription drug utilization management entity, that are designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy, or efficiency of prescription drugs including, but not limited to, prior authorization and step therapy protocols.
"Prescription drug utilization management entity" means an entity affiliated with, under contract with, or acting on behalf of a health carrier to perform prescription drug utilization management.
"Prior authorization" means a mandatory process that a carrier or prescription drug utilization management entity requires a provider or facility to follow to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan.
"Step therapy protocol" means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition will be covered by a health carrier.