Wash. Rev. Code § 48.43.780

Current through 2024

Section 48.43.780 - Cap on enrollee's required payment amount for specific drugs and equipment-Cost-sharing requirements

(1)

(a) Except as required in (b) of this subsection, a health plan issued or renewed on or after January 1, 2023, that provides coverage for prescription insulin drugs for the treatment of diabetes must cap the total amount that an enrollee is required to pay for a covered insulin drug at an amount not to exceed $35 per 30-day supply of the drug. Prescription insulin drugs must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.

(b) If the federal internal revenue service removes insulin from the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, for a health plan that provides coverage for prescription insulin drugs for the treatment of diabetes and is offered as a qualifying health plan for a health savings account, the carrier must establish the plan's cost sharing for the coverage of prescription insulin for diabetes at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from his or her health savings account under internal revenue service laws and regulations.

(2)

(a) Except as provided in (b) of this subsection, a health plan issued or renewed on or after January 1, 2025, that provides coverage for prescription asthma inhalers for the treatment of asthma shall cap the total amount that an enrollee is required to pay for at least one covered inhaled corticosteroid and at least one covered inhaled corticosteroid combination that is federal food and drug administration approved for the treatment of asthma at an amount not to exceed $35 per 30-day supply of the drug. A health plan must ensure that a covered inhaled corticosteroid and a covered inhaled corticosteroid combination is always available to a patient at the amount required by this subsection. Except as provided in (b) of this subsection, prescription asthma inhalers must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.

(b) For a health plan that is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for asthma inhalers that are not on the federal internal revenue service's list of preventive care services at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations. If the federal internal revenue service removes asthma inhalers from the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, for a health plan that provides coverage for prescription asthma inhalers for the treatment of asthma and is offered as a qualifying health plan for a health savings account, the carrier shall establish the plan's cost sharing for the coverage of prescription asthma inhalers at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from the enrollee's health savings account under internal revenue service laws and regulations.

(3)

(a) Except as provided in (b) of this subsection, a health plan issued or renewed on or after January 1, 2025, that provides coverage for prescription epinephrine autoinjectors for the treatment of allergic reaction shall cap the total amount that an enrollee is required to pay for at least one covered epinephrine autoinjector product containing at least two autoinjectors at an amount not to exceed $35. A health plan must ensure that a covered epinephrine autoinjector is always available to a patient at the amount required by this subsection. Except as provided in (b) of this subsection, prescription epinephrine autoinjectors must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.

(b) For a health plan that is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for epinephrine autoinjectors at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations. If the federal internal revenue service adds epinephrine autoinjectors to the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, coverage must be provided as described in (a) of this subsection without being subject to the deductible.

(4) The office of the insurance commissioner must provide written notice of any changes in internal revenue service guidance regarding any prescription drug covered in this section to affected parties, the chief clerk of the house of representatives, the secretary of the senate, the office of the code reviser, and others as deemed appropriate by the office.

(5) To the extent not prohibited under this section, health plans may apply drug utilization management strategies to prescription drugs covered under subsections (2) and (3) of this section.

RCW 48.43.780

Amended by 2024 c 226,§ 1, eff. 6/6/2024.

Amended by 2023 c 16,§ 1, eff. 7/23/2023.

Amended by 2022 c 10,§ 1, eff. 1/1/2023.

Added by 2020 c 346,§ 6, eff. 6/11/2020.

Added by 2020 c 245,§ 1, eff. 6/11/2020.

Effective date- 2022 c 10 s 1: "Section 1 of this act takes effect January 1, 2023." [2022 c 10 s 3.]

Intent- 2020 c 346 : See note following RCW 70.14.165.