RCW 48.43.785
COVID-19 personal protective equipment expenses
—
Health care provider reimbursement.
(Contingent expiration date.)
(1) For the duration of the federal public health emergency related to COVID-19, a health benefit plan shall reimburse a health care provider who bills for incurred personal protective equipment expenses as a separate expense, using the American medical association's current procedural terminology code 99072 or as subsequently amended, $6.57 for each individual patient encounter.
(2) For purposes of this section, cost sharing is limited to the covered service according to the terms and conditions of the health benefit plan and does not apply to an expense for personal protective equipment.
(3) This section is not intended to apply to health care services that are not provided in person.
[
2021 c 94 s 2
.]
NOTES:
Contingent expiration date
—
2021 c 94 s 2:
"Section 2 of this act expires upon the termination of the federal public health emergency related to COVID-19 as proclaimed by the United States department of health and human services." [
2021 c 94 s 5
.]
Findings
—
2021 c 94:
"(1) The legislature finds that:
(a) The delivery of health care services is essential and maintaining patient safety during the ongoing public health emergency is paramount;
(b) Pursuant to state and federal regulations, and in the interest of minimizing the risk of viral transmission, health care providers have incurred substantially increased costs during the public health emergency associated with the procurement of personal protective equipment;
(c) Costs associated with providing care are typically factored into contracts between a health carrier and a health care provider, but the dramatically increased personal protective equipment costs related to the pandemic, in terms of procurement and increased "per unit" costs, were neither foreseeable nor contemplated in existing contracts; and
(d) Health care providers do not want to bill patients directly for costs associated with personal protective equipment, and in many cases are precluded from doing so pursuant to terms of contract between health care providers and health carriers, so many health care providers currently do not have a mechanism to recoup costs of personal protective equipment.
(2) Therefore, the legislature finds that to help ensure patient safety and continued access to personal protective equipment, it is necessary that health carriers reimburse health care providers for costs associated with personal protective equipment." [
2021 c 94 s 1
.]
Application
—
2021 c 94:
"This act applies prospectively for the duration of the state of emergency related to COVID-19." [
2021 c 94 s 3
.]
Effective date
—
2021 c 94:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [April 16, 2021]." [
2021 c 94 s 4
.]
RCW 48.43.790
Behavioral services
—
Next-day appointments.
Health plans issued or renewed on or after January 1, 2023, must make next-day appointments available to enrollees experiencing urgent, symptomatic behavioral health conditions to receive covered behavioral health services. The appointment may be with a licensed provider other than a licensed behavioral health professional, as long as that provider is acting within their scope of practice, and may be provided through telemedicine consistent with RCW 48.43.735
. Need for urgent symptomatic care is associated with the presentation of behavioral health signs or symptoms that require immediate attention, but are not emergent.
[
2021 c 302 s 106
.]
NOTES:
Findings
—
Intent
—
2021 c 302:
See note following RCW 71.24.890
.
RCW 48.43.795
Qualified health plans
—
Acceptance of premium and cost-sharing assistance.
For qualified health plans offered on the exchange, a carrier shall:
(1) Accept payments for enrollee premiums or cost-sharing assistance under RCW 43.71.110
or as part of a sponsorship program under RCW 43.71.030
(4). Nothing in this subsection expands or restricts the types of sponsorship programs authorized under state and federal law;
(2) Clearly communicate premium assistance amounts to enrollees as part of the invoicing and payment process; and
(3) Accept and process enrollment and payment data transferred by the exchange in a timely manner.
[
2021 c 246 s 4
.]
RCW 48.43.800
Primary care expenditures reporting
—
Review.
(1) The commissioner may require health carriers to annually report primary care expenditures in previous calendar years or anticipated for upcoming calendar years.
(2) The commissioner may determine the form and content of carrier primary care expenditure reporting. In developing the form and content for reporting, the commissioner shall consider the definition of primary care expenditures and any primary care expenditure targets established under RCW 70.390.080
as well as primary care expenditure reporting systems implemented by the health care authority for medical assistance and employee benefits coverage administered under chapter
41.05
or
74.09
RCW.
(3) Primary care expenditure reports submitted by carriers under this section are public information.
[
2025 c 6 s 1
;
2022 c 155 s 2
.]
RCW 48.43.805
Prescription drug upper payment limit
—
Rules.
(1) For health plans issued or renewed on or after January 1, 2024, if the prescription drug affordability board, as established in chapter
70.405
RCW, establishes an upper payment limit for a prescription drug pursuant to RCW 70.405.050, a carrier must provide sufficient information, as determined by the commissioner, to indicate that reimbursement for a claim for that prescription drug will not exceed the upper payment limit for the drug established by the board.
(2) The commissioner may adopt any rules necessary to implement this section.
[
2022 c 153 s 10
.]
RCW 48.43.810
Biomarker testing
—
Standards
—
Construction.
(1) Health plans issued or renewed on or after January 1, 2023, shall exempt an enrollee from prior authorization requirements for coverage of biomarker testing for either of the following:
(a) Stage 3 or 4 cancer; or
(b) Recurrent, relapsed, refractory, or metastatic cancer.
(2) For purposes of this section, "biomarker test" means a single or multigene diagnostic test of the cancer patient's biospecimen, such as tissue, blood, or other bodily fluids, for DNA, RNA, or protein alterations, including phenotypic characteristics of a malignancy, to identify an individual with a subtype of cancer, in order to guide patient treatment.
(3) For purposes of this section, biomarker testing must be:
(a) Recommended in the latest version of nationally recognized guidelines or biomarker compendia, such as those published by the national comprehensive cancer network;
(b) Approved by the United States food and drug administration or a validated clinical laboratory test performed in a clinical laboratory certified under the clinical laboratory improvement amendments or in an alternative laboratory program approved by the centers for medicare and medicaid services;
(c) A covered service; and
(d) Prescribed by an in-network provider.
(4) This section does not limit, prohibit, or modify an enrollee's rights to biomarker testing as part of an approved clinical trial under chapter
69.77
RCW.
(5) Nothing in this section may be construed to mandate coverage of a health care service.
(6) Nothing in this section prohibits a health plan from requiring a biomarker test prior to approving a drug or treatment.
(7) This section does not limit an enrollee's rights to access individual gene tests.
[
2022 c 123 s 1
.]
RCW 48.43.815
Donor human milk
—
Standards.
(1) For group health plans other than small group health plans issued or renewed on or after January 1, 2023, a health carrier shall provide coverage for medically necessary donor human milk for inpatient use when ordered by a licensed health care provider with prescriptive authority or an international board certified lactation consultant certified by the international board of lactation consultant examiners for an infant who is medically or physically unable to receive maternal human milk or participate in chest feeding or whose parent is medically or physically unable to produce maternal human milk in sufficient quantities or caloric density or participate in chest feeding, if the infant meets at least one of the following criteria:
(a) An infant birth weight of below 2,500 grams;
(b) An infant gestational age equal to or less than 34 weeks;
(c) Infant hypoglycemia;
(d) A high risk for development of necrotizing enterocolitis, bronchopulmonary dysplasia, or retinopathy of prematurity;
(e) A congenital or acquired gastrointestinal condition with long-term feeding or malabsorption complications;
(f) Congenital heart disease requiring surgery in the first year of life;
(g) An organ or bone marrow transplant;
(h) Sepsis;
(i) Congenital hypotonias associated with feeding difficulty or malabsorption;
(j) Renal disease requiring dialysis in the first year of life;
(k) Craniofacial anomalies;
(l) An immunologic deficiency;
(m) Neonatal abstinence syndrome;
(n) Any other serious congenital or acquired condition for which the use of pasteurized donor human milk and donor human milk derived products is medically necessary and supports the treatment and recovery of the child; or
(o) Any baby still inpatient within 72 hours of birth without sufficient human milk available.
(2) Donor human milk covered under this section must be obtained from a milk bank that meets minimum standards adopted by the department of health pursuant to RCW 43.70.645
.
(3) For purposes of this section:
(a) "Donor human milk" means human milk that has been contributed to a milk bank by one or more donors.
(b) "Milk bank" means an organization that engages in the procurement, processing, storage, distribution, or use of human milk contributed by donors.
(4) The commissioner may adopt any rules necessary to implement this section.
[
2022 c 236 s 1
.]
RCW 48.43.820
Consolidated appropriations act enforcement
—
Implementation of federal regulations.
The commissioner is authorized to enforce provisions of P.L. 116-260 (enacted December 27, 2020, as the consolidated appropriations act of 2021) and implementing federal regulations in effect on March 31, 2022, that are applicable to or regulate the conduct of carriers issuing health plans or grandfathered health plans to residents of Washington state on or after January 1, 2022. In addition to the enforcement actions authorized under RCW 48.02.080, the commissioner may impose a civil monetary penalty in an amount not to exceed $100 for each day for each individual with respect to which a failure to comply with these provisions occurs.
[
2022 c 263 s 5
.]
NOTES:
Effective date
—
2022 c 263:
See note following RCW 43.371.100
.
RCW 48.43.825
Certified peer support specialist services
—
Network access standards.
By July 1, 2026, each carrier shall provide access to services provided by certified peer support specialists and certified peer support specialist trainees in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance commissioner.
[
2025 c 360 s 16
;
2023 c 469 s 16
.]
RCW 48.43.830
Prior authorization.
(Effective until January 1, 2027.)
(1) Each carrier offering a health plan issued or renewed on or after January 1, 2024, shall comply with the following standards related to prior authorization for health care services and prescription drugs:
(a) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through an electronic prior authorization process, as designated by each carrier:
(i) For electronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within three calendar days, excluding holidays, of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(ii) For electronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(b) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process:
(i) For nonelectronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within five calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within five calendar days of submission of the nonelectronic prior authorization request.
(ii) For nonelectronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the nonelectronic prior authorization request.
(c) In any instance in which a carrier has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, a carrier may establish a specific reasonable time frame for submission of the additional information. This time frame must be communicated to the provider and enrollee with a carrier's request for additional information.
(d) The carrier's prior authorization requirements must be described in detail and written in easily understandable language. The carrier shall make its most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request. The prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must be evaluated and updated, if necessary, at least annually.
(2)(a) Each carrier shall establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535
.
(b) Each carrier shall establish and maintain an interoperable electronic process or application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug. The interoperable electronic process or application programming interface must support the exchange of prior authorization requests and determinations for prescription drugs, including information on covered alternative prescription drugs, beginning January 1, 2027, and must:
(i) Allow providers to identify prior authorization information and documentation requirements;
(ii) Facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system; and
(iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535
.
(c) Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized by the federal centers for medicare and medicaid services after February 8, 2024, the requirements of (a) of this subsection shall be enforced beginning January 1, 2027.
(d) By September 13, 2023, and at least every six months thereafter until September 13, 2026, the commissioner shall provide an update to the health care policy committees of the legislature on the development of rules and implementation guidance from the federal centers for medicare and medicaid services regarding the standards for development of application programming interfaces and interoperable electronic processes related to prior authorization functions. The updates should include recommendations, as appropriate, on whether the status of the federal rule development aligns with the provisions of chapter 382, Laws of 2023. The commissioner also shall report on any actions by the federal centers for medicare and medicaid services to exercise enforcement discretion related to the implementation and maintenance of an application programming interface for prior authorization functions. The commissioner shall consult with the health care authority, carriers, providers, and consumers on the development of these updates and any recommendations.
(3) Nothing in this section applies to prior authorization determinations made pursuant to RCW 48.43.761
.
(4) For the purposes of this section:
(a) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:
(i) The passage of time:
(A) Could seriously jeopardize the life or health of the enrollee;
(B) Could seriously jeopardize the enrollee's ability to regain maximum function; or
(C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request; or
(ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.
(b) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service or prescription drug that is not required to be expedited.
[
2025 c 25 s 1
;
2023 c 382 s 1
.]
PDF
RCW 48.43.830
Prior authorization.
(Effective January 1, 2027.)
(1) Each carrier offering a health plan issued or renewed on or after January 1, 2024, shall comply with the following standards related to prior authorization for health care services and prescription drugs:
(a) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through an electronic prior authorization process, as designated by each carrier:
(i) For electronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within three calendar days, excluding holidays, of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(ii) For electronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(b) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process:
(i) For nonelectronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within five calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within five calendar days of submission of the nonelectronic prior authorization request.
(ii) For nonelectronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the nonelectronic prior authorization request.
(c) In any instance in which a carrier has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, a carrier may establish a specific reasonable time frame for submission of the additional information. This time frame must be communicated to the provider and enrollee with a carrier's request for additional information.
(d) The carrier's prior authorization requirements must be described in detail and written in easily understandable language. The carrier shall make its most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request. The prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must be evaluated and updated, if necessary, at least annually. Clinical review criteria used for purposes of reviewing and decided upon prior authorization requests related to mental health and substance use disorder services, as defined in RCW 48.43.766, must meet the requirements of RCW 48.43.766
.
(2)(a) Each carrier shall establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535
.
(b) Each carrier shall establish and maintain an interoperable electronic process or application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug. The interoperable electronic process or application programming interface must support the exchange of prior authorization requests and determinations for prescription drugs, including information on covered alternative prescription drugs, beginning January 1, 2027, and must:
(i) Allow providers to identify prior authorization information and documentation requirements;
(ii) Facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system; and
(iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535
.
(c) Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized by the federal centers for medicare and medicaid services after February 8, 2024, the requirements of (a) of this subsection shall be enforced beginning January 1, 2027.
(d) By September 13, 2023, and at least every six months thereafter until September 13, 2026, the commissioner shall provide an update to the health care policy committees of the legislature on the development of rules and implementation guidance from the federal centers for medicare and medicaid services regarding the standards for development of application programming interfaces and interoperable electronic processes related to prior authorization functions. The updates should include recommendations, as appropriate, on whether the status of the federal rule development aligns with the provisions of chapter 382, Laws of 2023. The commissioner also shall report on any actions by the federal centers for medicare and medicaid services to exercise enforcement discretion related to the implementation and maintenance of an application programming interface for prior authorization functions. The commissioner shall consult with the health care authority, carriers, providers, and consumers on the development of these updates and any recommendations.
(3) Nothing in this section applies to prior authorization determinations made pursuant to RCW 48.43.761
.
(4) For the purposes of this section:
(a) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:
(i) The passage of time:
(A) Could seriously jeopardize the life or health of the enrollee;
(B) Could seriously jeopardize the enrollee's ability to regain maximum function; or
(C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request; or
(ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.
(b) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service or prescription drug that is not required to be expedited.
[
2025 c 227 s 8
;
2025 c 25 s 1
;
2023 c 382 s 1
.]
NOTES:
Reviser's note:
This section was amended by 2025 c 25 s 1 and by 2025 c 227 s 8, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025
(2). For rule of construction, see RCW 1.12.025
(1).
Effective date
—
2025 c 227 ss 1-8:
See note following RCW 48.43.766
.
Findings
—
Intent
—
Rules
—
2025 c 227:
See notes following RCW 48.43.766
.
RCW 48.43.835
Physician assistants
—
Coverage.
This chapter authorizes carriers to reimburse employers of physician assistants for covered services rendered by licensed physician assistants. Payment for services within the physician assistant's scope of practice must be made when ordered or performed by a physician assistant if the same services would have been covered if ordered or performed by a physician. Physician assistants or their employers, who are billing on behalf of the physician assistant, are authorized to bill for and receive direct payment for the services delivered by physician assistants. A carrier may not impose a practice, education, or collaboration requirement that is inconsistent with or more restrictive than state laws or regulations governing physician assistants.
[
2024 c 62 s 11
.]
NOTES:
Effective date
—
2024 c 62 ss 1-8, 10-18, 20-26, 28, and 30-32:
See note following RCW 18.71A.010
.
Intent
—
2024 c 62:
See note following RCW 18.71A.020
.
RCW 48.43.840
Prosthetic limbs and custom orthotic braces
—
Coverage
—
Reporting.
(1) Except as provided in subsection (9) of this section, a health plan offered in the large group or small group market that is issued or renewed on or after January 1, 2026, must include coverage for one or more prostheses per limb and custom orthotic braces per limb when medically necessary for the enrollee to participate in any of the following:
(a) Completing activities of daily living or essential job-related activities; and
(b) Performing physical activities, including but not limited to running, biking, swimming, and strength training, for maximizing the enrollee's lower limb function, upper limb function, or both.
(2) The coverage required under this section must also include coverage for:
(a) Materials, components, and related services necessary to use the devices for their intended purposes;
(b) Instruction to the enrollee on using the devices; and
(c) Reasonable repair or replacement of the devices.
(3)(a) Coverage under this section includes coverage for the replacement or repair of a prosthetic limb or custom orthotic brace or for the replacement or repair of any part of such devices, without regard to continuous use or useful lifetime restrictions, if medically necessary because:
(i) Of a change in the physiological condition of the patient;
(ii) Of an irreparable change in the condition of the device or a part of the device; or
(iii) The device, or any part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device or of the part being replaced.
(b) Confirmation from the prescribing health care provider may be required if the prosthetic limb or custom orthotic brace or part being replaced is less than three years old.
(4) A health plan offered in the large group or small group market may not deny coverage for a prosthetic limb or custom orthotic brace for an enrollee with a disability if health care services would otherwise be covered for a nondisabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
(5) For coverage under this section, a health plan offered in the large group or small group market may apply normal utilization management and prior authorization practices. Any denial of coverage must be issued in writing with an explanation for determining coverage was not medically necessary.
(6) A health plan offered in the large group or small group market shall provide payment for coverage under this section that is at least equal to the payment and coverage for prosthetic limbs and custom orthotic braces provided under federal laws and regulations for the aged and disabled pursuant to 42 U.S.C. Sec. 1395k, 1395l, and 1395m and 42 C.F.R. Sec. 414.202, 414.210, 414.228, and 410.100.
(7) No later than July 1, 2028, each carrier that issues a health plan subject to this section shall report to the office of the insurance commissioner, in a form and manner determined by the commissioner, the number of claims and the total amount of claims paid in the state for the services required by this section for plan years 2026 and 2027. The commissioner shall aggregate this data by plan year in a report and submit the report to the relevant committees of the legislature by December 1, 2028.
(8) For the purposes of this section:
(a) "Prosthetic limb" or "prosthesis" means an external medical device that is used to replace or restore a missing limb or portion of a limb and is deemed medically necessary for an individual with a mobility impairing health condition or disability.
(b) "Custom orthotic brace" means an external medical device that is custom-fabricated or custom-fitted to support, correct, or alleviate neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity, is needed to improve the safety and efficiency of functional mobility, is patient-specific based on the patient's unique physical condition, and is deemed medically necessary for individuals with a mobility impairing health condition or disability.
(9) This section does not apply to health plans offered in the individual market or to self-insured or fully insured large group health plans offered to public employees and school employees under chapter
41.05
RCW.
[
2025 c 96 s 1
.]
RCW 48.43.845
Prescription hormone therapy
—
Coverage.
(1) A health plan issued or renewed on or after January 1, 2026, that includes coverage for prescription hormone therapy must provide reimbursement for a 12-month refill of covered prescription hormone therapy obtained at one time by the enrollee, unless the enrollee requests a smaller supply, the prescribing provider instructs that the enrollee must receive a smaller supply, or the prescription hormone therapy is a controlled substance. The 12-month refill requirement only applies to prescription hormone therapy that is able to be safely stored at room temperature without refrigeration. If the prescription hormone therapy is a controlled substance, the health plan must provide reimbursement for the maximum refill allowed under state and federal law to be obtained at one time by the enrollee. Any dispensing practices required by the health plan must follow clinical guidelines for appropriate prescribing and dispensing to ensure the health of the patient while maximizing access to effective prescription hormone therapy.
(2) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a 12-month supply of the prescription hormone therapy has already been dispensed during the plan year.
(3) Nothing in this section prohibits a prescribing provider from temporarily limiting refills that may be obtained to a 90-day supply at one time if the prescription hormone therapy is experiencing an acute dispensing shortage during the plan year provided limits must be rescinded at first opportunity of a regularly reinstated, sustainable supply.
(4) To the extent not otherwise prohibited under this section or state or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under subsection (1) of this section.
(5) For purposes of this section, "prescription hormone therapy" means all drugs approved by the United States food and drug administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels. Prescription hormone therapy does not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.
[
2025 c 171 s 1
.]
RCW 48.43.902
Effective date
—
1996 c 312.
This act shall take effect July 1, 1996.
[
1996 c 312 s 8
.]
RCW 48.43.904
Construction
—
Chapter applicable to state registered domestic partnerships
—
2009 c 521.
For the purposes of this chapter, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to state registered domestic partnerships or individuals in state registered domestic partnerships as well as to marital relationships and married persons, and references to dissolution of marriage shall apply equally to state registered domestic partnerships that have been terminated, dissolved, or invalidated, to the extent that such interpretation does not conflict with federal law. Where necessary to implement chapter 521, Laws of 2009, gender-specific terms such as husband and wife used in any statute, rule, or other law shall be construed to be gender neutral, and applicable to individuals in state registered domestic partnerships.
[
2009 c 521 s 125
.]