Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5080 - Prescription drug benefit design

Current through Register Vol. 24-14, July 15, 2024
(1) A carrier may design its prescription
				drug benefit to include cost control measures, including requiring preferred
				drug substitution in a given therapeutic class, if the restriction is for a
				less expensive, equally therapeutic alternative product available to treat the
				condition.
(2) A carrier may
				include elements in its prescription drug benefit design that, where clinically
				feasible, create incentives for the use of generic drugs. Examples of permitted
				incentives include, but are not limited to, refusal to pay for higher cost
				drugs until it can be shown that a lower cost drug or medication is not
				effective (also known as step therapy protocols or fail-first policies),
				establishing a preferred brand and nonpreferred brand formulary, or otherwise
				limiting the benefit to the use of a generic drug in lieu of brand name drugs,
				subject to a substitution process as set forth in subsection (3) of this
				section.
(3) A carrier may include
				a preauthorization requirement for its prescription drug benefit and its
				substitution process, based on accepted peer reviewed clinical studies, Federal
				Drug Administration black box warnings, the fact that the drug is available
				over-the-counter, objective and relevant clinical information about the
				enrollee's condition, specific medical necessity criteria, patient safety, or
				other criteria that meet an accepted, medically applicable standard of
				care.
(4) A carrier may require an
				enrollee to try an AB-rated generic equivalent or a biological product that is
				an interchangeable biological product prior to providing coverage for the
				equivalent branded prescription drug.
(5) A nongrandfathered health plan issued or
				renewed on or after January 1, 2023, that provides coverage for prescription
				drugs must comply with
				RCW
				 48.43.435.
(a)
For the purposes of this
				subsection,
any cost sharing amount paid directly by or on behalf of the
				enrollee by another person for a covered prescription drug, at the time it is
				rendered, must be applied in full toward the enrollee's applicable cost-sharing
				as defined in WAC
				284-43-0160 and out-of-pocket
				maximum as defined in
				RCW
				 48.43.005 consistent with
				RCW
				 48.43.435.
(b) If an enrollee requests an exception
				under RCW
				 48.43.420 or appeals a denial of an exception
				request, and the request or appeal is still pending, any amount paid by or on
				behalf of an enrollee for a covered prescription drug must be applied towards
				the enrollee's contribution to any applicable deductible, copayment,
				coinsurance, or out-of-pocket maximum until the review is resolved and the
				status of the request is communicated to the carrier.
(c) The health carrier must disclose to the
				enrollee information about when third-party payments, including payments made
				through application of a manufacturer drug coupon or other manufacturer
				discount, are applied towards the enrollee's annual cost-sharing obligations,
				including applicable deductibles, copayments, coinsurances, or out-of-pocket
				maximums. The disclosure shall be included in the certificate of coverage (also
				commonly referred to as the member booklet or member handbook). Carriers are
				not required to use verbatim language from either the statute or regulation;
				however, the information provided to the enrollee about the application of
				third-party payments must be sufficiently detailed to address the situations
				set forth in
				RCW
				 48.43.435(1)(a)(i) through
				(iii).