Committee hears bill to limit step therapy for metastatic cancer; debate focuses on 'associated conditions' language

Senate Bill 422 would curb insurers' use of step therapy for people with advanced, potentially terminal cancer, returning treatment decisions to treating clinicians for those patients, proponents told the House Business and Labor Committee.

Sponsor testimony opened with a personal account about metastatic cancer and the limits of "step therapy," which is commonly called "fail first" by patients. "Step therapy is often called by patients fail first," said Becky Franks, a cancer support advocate, describing delays in access to newer or personalized cancer treatments.

Proponents included patient advocates, cancer survivors and medical organizations. Bobby Will of Susan G. Komen said metastatic breast cancer "is highly personalized and must be based on the decision made between the patient and the health care provider." Elizabeth Harris, a 30-year metastatic breast cancer survivor, said her life depended on a physician-chosen regimen and urged the committee to pass the bill with a proposed amendment.

Medical groups — including the Montana Medical Association and doctors testifying for oncology and primary care organizations — said the bill includes an amendment to tie coverage decisions to National Comprehensive Cancer Network (NCCN) guidance, which many oncologists use.

Insurers and pharmacy benefit managers voiced concerns about broad language in the bill that would bar step therapy for metastatic cancer "and associated conditions." Greg Van Horson of Prime Therapeutics and Bruce Spencer (representing Mountain Health Co-op and Cigna) urged removing the phrase "associated conditions" so the law would apply only to metastatic cancer treatments, arguing the broader language could unintentionally affect ancillary care such as nausea or anemia management. "We believe... focusing this bill directly on metastatic cancer... will make it more predictable," Van Horson said.

Public commenters asked the committee to expand coverage to certain other terminal conditions (for example, high-grade glioma) not always staged as metastatic by clinicians; the sponsor indicated willingness to work with medical groups on language to include those diagnoses where clinically appropriate.

What the bill would do: Under the current draft proponents discussed, an insurer could not require a patient with advanced metastatic cancer to try a plan-preferred drug and "fail" before receiving the drug the patient's clinician prescribed. The bill contains an amendment referencing NCCN guidelines as part of an exception process proponents said would preserve clinical standards.

Why it matters: Proponents said delay from step therapy can shorten survival or increase suffering for patients with terminal disease; opponents said the bill as drafted could widen its scope beyond oncology treatment when the phrase "associated conditions" is read broadly.

Next steps: The sponsor and insurers said they will continue to negotiate amendments, including a proposal to remove "associated conditions" and a separate proposal to add specific terminal diagnoses; committee action was not recorded in the transcript.