Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5110 - Cost-sharing for prescription drugs

Current through Register Vol. 24-14, July 15, 2024
(1) A carrier and health plan unreasonably
				restrict the treatment of patients if an ancillary charge, in addition to the
				plan's normal copayment or coinsurance requirements, is imposed for a drug that
				is covered because of one of the circumstances set forth in either WAC
				284-43-5080 or
				284-43-5100. An ancillary charge
				means any payment required by a carrier that is in addition to or excess of
				cost-sharing explained in the policy or contract form as approved by the
				commissioner. Cost-sharing means amounts paid directly to a provider or
				pharmacy by an enrollee for services received under the health benefit plan,
				and includes copay-ment, coinsurance, or deductible amounts.
(2) When an enrollee requests a brand name
				drug from the formulary in lieu of a therapeutically equivalent generic drug or
				a drug from a higher tier within a tiered formulary, and there is not a
				documented clinical basis for the substitution, a carrier may require the
				enrollee to pay for the difference in price between the drug that the formulary
				would have required, and the covered drug, in addition to the copayment. This
				charge must reflect the actual cost difference.
(3) When a carrier approves a substitution
				drug, whether or not the drug is in the carrier's formulary, the enrollee's
				cost-sharing for the substitution drug must be adjusted to reflect any discount
				agreements or other pricing adjustments for the drug that are available to a
				carrier. Any charge to the enrollee for a substitution drug must not increase
				the carrier's underwriting gain for the plan beyond the gain contribution
				calculated for the original formulary drug that is replaced by the
				substitution.
(4) If a carrier uses
				a tiered formulary in its prescription drug benefit design, and a substitute
				drug that is in the formulary is required based on one of the circumstances in
				either WAC
				284-43-5080 or
				284-43-5100, the enrollee's cost
				sharing may be based on the tier in which the carrier has placed the substitute
				drug.
(5) If a carrier requires
				cost-sharing for enrollees receiving an emergency fill as defined in WAC
				284-170-470, then issuers must
				disclose that information to enrollees within their policy forms.
(6) For individual and small group plans, if
				a substitution is granted, the carrier must treat the drug as an essential
				health benefit, including by counting any cost-sharing towards the plan's
				annual limitation on cost-sharing and towards any deductible.
Reviser's note:
The bracketed material
					 preceding the section above was supplied by the code reviser's office.
Reviser's note:
RCW
					  34.05.395 requires the use of underlining and
					 deletion marks to indicate amendments to existing rules. The rule published
					 above varies from its predecessor in certain respects not indicated by the use
					 of these markings.