Stage Four Advanced, Metastatic Cancer Step Therapy HB 261/SB 672

Step therapy also referred to as “fail first”, requires a patient to first try a preferred (often generic alternative) drug prior to receiving coverage for the originally prescribed drug.  Step therapy is a method of utilization management health plans employ to control costs by beginning treatment with more cost-effective drug therapy and then progressing to the newer, more costly treatments only if necessary. Legislation can prohibit health plan companies from requiring enrollees to follow step therapy protocols for stage four advanced metastatic cancer. This legislation does not prohibit the use of generics for treatments and only serves to ensure that the patient has access to most appropriate treatment for their condition.

  • Currently, in the U.S. more than 154,000 people are living with metastatic breast cancer. Metastatic breast cancer is an advanced stage of breast cancer where tumor cells have spread to other parts of the body. It is estimated that nearly all of the more than 42,000 breast cancer deaths expected this year will be a result of metastasis.
  • Although metastatic breast cancer cannot be cured, it can be treated. Treatments are highly personalized and must be based on decisions made by the patient and their healthcare providers, as they are most capable in determining the appropriate treatment for patients. Unfortunately, most step therapy protocols rely on generalized information regarding patients and their treatments as opposed to considering unique patient experiences, and responses to different treatments.
  • Due to the spread of cancer to other parts of the body, a majority of patients suffer from a number of associated conditions including comorbidities, symptoms and/or side effects (i.e. weakening of bone, anemia, central nervous system issues, pain, etc).


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