Bill
SB 5300
Protects continuity of behavioral health meds by barring mid‑year substitutions or higher cost-sharing for patients with serious mental illness stable on therapy, starting 2025.
Status / Procedural history
- Enacted as Substitute Senate Bill 5300 (68th Leg., 2023 Regular Session). Passed both chambers unanimously; Governor signed May 4, 2023. Chapter 325, 2023 Laws. The statute contains multiple effective dates; key operative provisions apply to plans issued or renewed on or after January 1, 2025.
- Amends RCW 69.41.190 and adds a new section to chapter 48.43 RCW.
Purpose
- To promote continuity of medication for people with serious mental illness by limiting mid‑plan‑year formulary substitutions and cost‑sharing increases for certain behavioral health drugs when a patient is stable on therapy and the prescriber continues that treatment. It also expands protections in state‑purchased health care programs against pharmacist substitution for refills of such drugs.
Key provisions
- Health carrier / PBM restrictions (new section in chapter 48.43 RCW)
- For health plans with prescription coverage issued or renewed on or after Jan 1, 2025, a health carrier or its health care benefit manager may not, mid‑plan‑year:
- require substitution of a prescribed nonpreferred drug with a preferred drug in the same therapeutic class; or
- increase an enrollee’s cost‑sharing for the drug;
- if all of the following are true:
- the prescription is a refill of an antipsychotic, antidepressant, antiepileptic, or other drug prescribed to treat a serious mental illness;
- the enrollee is medically stable on the drug; and
- a participating provider continues to prescribe the drug.
- Explicit exceptions: carriers may require generic substitution during the plan year; may add new drugs to formularies; may remove drugs for patient safety, recalls, market removal, or evidence of no therapeutic effect; and providers may prescribe different covered drugs that are medically appropriate.
Definitions added or clarified
- "Serious mental illness" — defined by reference to the most recent DSM edition: a mental disorder resulting in serious functional impairment in one or more major life activities.
- "Refill" — defined as a second or subsequent filling of a previously issued prescription.
Who is affected
- Primary: enrollees with serious mental illness who are stable on medication; prescribing providers.
- Regulated entities: health carriers and their health care benefit managers (PBMs); pharmacies and pharmacists operating under state‑purchased health care programs.
- State programs: Department of Social and Health Services, Health Care Authority, L&I, Corrections, Veterans Affairs, local school districts insofar as they participate in state‑purchased programs.
Timing and implementation
- Although the bill chapter was enacted in 2023, the protections for commercial and public plan formularies and the pharmacist substitution changes are tied to January 1, 2025 (applies to plans issued or renewed on or after that date and to refill dispensing under state‑purchased programs beginning Jan 1, 2025).
Fiscal/other notes
- No appropriation included. A fiscal note was prepared (details in legislative fiscal documents).
- The law preserves flexibility for carriers to manage formularies for safety and cost reasons while adding a continuity‑of‑care safeguard for patients with serious mental illness.
Practical effect
- Intended to reduce disruptive, mid‑year changes in medication or costs that can destabilize patients with serious mental illness by ensuring they can continue stable, prescriber‑directed therapies without forced substitution or higher cost sharing during a plan year, subject to stated exceptions.
Compiled from official sources — confirm details with the bill’s official record.
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