HEALTH CARE AUTHORITY

(Washington Apple Health)

Under RCW 69.41.190 and 70.14.050, the ((department)) medicaid agency and other state agencies cooperate in developing and maintaining the Washington preferred drug list (PDL).

(1) Washington state contracts with evidence-based practice center((())s(())) for systematic drug reviews ((of drug(s))).

(2) The pharmacy and therapeutics (P&T) committee reviews and evaluates the safety, efficacy, and outcomes of prescribed drugs, using evidence-based information provided by the evidence-based practice center((())s(())).

(3) The P&T committee makes recommendations to state agencies as to which drug((())s(())) to include on the Washington PDL under chapter 182-50 WAC.

(4) The appointing authority makes the final selection of drugs included on the Washington PDL.

(5) Drugs in a drug class on the Washington PDL that have been studied by ((the)) an evidence-based practice center(((s))) and reviewed by the P&T committee and which have not been selected as preferred are considered nonpreferred drugs and are subject to the therapeutic interchange program (TIP) and dispense as written (DAW) rules under WAC ((388-530-4150)) 182-530-4150.

(6) Drugs in a drug class on the Washington PDL that have not been studied by ((the)) an evidence-based practice center(((s))) and have not been reviewed by the P&T committee will be treated as nonpreferred drugs not subject to the dispense as written (DAW) or the therapeutic interchange program (TIP).

(7) A nonpreferred drug which the ((department)) agency determines as covered is considered for authorization after the client has:

(a) Tried and failed or is intolerant to at least one preferred drug; and

(b) Met ((department)) agency-established criteria for the nonpreferred drug.

(8) Drugs in a drug class on the Washington PDL may be designated as preferred drugs for special populations or specific indications.

(9) Drugs in a drug class on the Washington PDL may require authorization for safety.

(10) Combination drugs that have been studied by ((the)) an evidence-based practice center and have been reviewed by the P&T committee may be included in the Washington PDL.

(11) When a brand-name drug has been reviewed by the P&T committee, the ((department)) agency may immediately designate an available, less expensive, equally effective, generic equivalent as a preferred drug. For the purpose of this chapter, generic equivalent drugs are those identified in the ((FDA's)) Food and Drug Administration's approved drug products with therapeutic equivalence evaluations (orange book).

(12) The dispensing of a brand name or nonpreferred generic drug in a drug class on the Washington PDL as a client's first course of treatment within that therapeutic class may be subject to restrictions under WAC ((388-530-4125 and WAC 388-530-4150(10))) 182-530-4125 and 182-530-4150(10).

The ((department)) medicaid agency uses point-of-sale (POS) claim messaging to ((communicate to)) tell pharmacies to use a preferred generic drug for the client's first course of treatment in specific drug classes.

(1) The ((department)) agency may require preferred generic drug((())s(())) on the Washington preferred drug list (PDL) be used before any brand name or nonpreferred generic drugs for a client's first course of treatment within that therapeutic class of drugs, when:

(a) There is a less expensive, equally effective therapeutic alternative generic product available to treat the condition; and

(b) The drug use review (DUR) board established under WAC ((388-530-4000)) 182-530-4000 has reviewed the drug class and recommended to the ((department)) agency that the drug class is appropriate to require generic drugs as a client's first course of treatment.

(2) For drug classes selected by the ((department which)) agency that meet the criteria of subsection (1) of this section, only preferred generic drugs are covered for a client's first course of treatment, except as identified in subsection (3) of this section.

(3) Endorsing practitioners' prescriptions written "Dispense as written (DAW)" for preferred and nonpreferred brand name drugs and nonpreferred generics in the specific drug classes on the Washington PDL reviewed by the DUR board will be subject to authorization to establish medical necessity as defined in WAC ((388-500-0005)) 182-500-0070.