In 2005, the Legislature directed the Health Care Authority (HCA) to establish a prescription drug purchasing consortium. The Northwest Prescription Drug Consortium allows state agencies, local governments, businesses, labor organizations, and uninsured consumers to pool their purchasing power to purchase prescription drugs at lower prices. The consortium offers access to retail pharmacy discounts, pharmacy benefit management services, rebate management services, and a prescription discount card for uninsured residents.
Statutory authority allows for drug purchasing cost controls including negotiating discounts with manufacturers, central purchasing, volume contracting, and setting maximum prices to be paid.
In 2019, the Legislature passed prescription drug cost transparency legislation. The legislation requires:
Prescription Drug Affordability Board Duties. The Prescription Drug Affordability Board (Board) is established within HCA with five members appointed by the Governor, who have expertise in health care economics or clinical medicine. By June 30, 2023, and yearly thereafter, the Board must identify:
The Board may choose to conduct an affordability review of any drug it identifies meeting the above thresholds. When deciding whether to conduct a review, the Board must consider:
For any drug chosen for a review, the Board must establish an advisory group consisting of relevant stakeholders, including patients and patient advocates for the condition treated by the drug.
Affordability reviews must determine if the drug has led or will lead to excess costs, defined as costs exceeding therapeutic benefit relative to other treatments, or are not sustainable to the health care system over a 10-year period. When conducting a review, the board must consider:
The Board may request confidential and proprietary information about the drug from the manufacturer to complete its review, and the manufacturer must submit all requested information within 30 days. HCA may assess a fine up to $100,000 against a manufacturer for each failure to comply with an information request.
The Board must establish a methodology for setting upper payment limits for prescription drugs that the Board has determined have led or will lead to excess costs based on its affordability review. The methodology must consider:
Each year, beginning January 1, 2024, the board may set an upper payment limit for up to 12 prescription drugs. An upper payment limit for a prescription drug applies to all purchases of the drug by any entity and reimbursements for a claim for the drug by a health carrier when the drug is dispensed or administered to an individual in the state. Employer-sponsored self-funded plans may elect to be subject to the upper payment limits.
The effective date of an upper payment limit must be at least six months after the adoption of the limit by the Board. The Board may reassess the upper payment limit for any drug annually based on current economic factors.
Use of Savings. Any savings generated for a health plan that are attributable to the establishment of an upper payment limit must be used to reduce costs to consumers, prioritizing the reduction of out-of-pocket costs for prescription drugs. By January 1, 2024, the Board must establish a formula for calculating savings for complying with this section.
By March 1st of the year following the effective date of the first upper payment limit, and annually thereafter, each state agency and health carrier issuing a health plan in the state must submit a report to the board describing the savings in the previous calendar year that were attributable to upper payment limits and how the savings were used to reduce costs to consumers.
Manufacturer Withdrawal. If a manufacturer chooses to withdraw a drug from the market due to an upper payment limit for that drug, it must provide written notice to the state at least 180 days in advance. If a manufacturer withdraws a drug, it will be prohibited from selling the drug in the state for five years, unless it petitions HCA to reenter the market on the condition that it will make the drug available in compliance with the upper payment limit.
Price Increase Penalty. If the Board determines, after an affordability review, that a drug will result in excess costs for patients, but does not impose an upper payment limit on the drug, the Department of Revenue must impose a penalty on the increased revenue generated in the state resulting from the price increase. The penalty must be 80 percent of the difference between the revenue generated by sales within the state and the revenue that would have been generated if the manufacturer had maintained the wholesale acquisition cost from the previous calendar year.
Data Access. The prescription drug price transparency statutes are amended to allow the board to review all data collected pursuant to that program for conducting affordability review.
PRO: The prices for drugs continue to go up, which leads to higher insurance premiums. People need to be able to afford drugs for conditions they have no control over. Even with insurance covering high priced drugs it is impossible for many patients to afford the out-of-pocket expenses. Drugs are the fastest growing part of insurance premiums. High drug prices disproportionately affect seniors and those with chronic health conditions.
CON: This bill goes too far and could reduce access to drugs. The bill doesn't account for negotiations on price and might lead to carriers or pharmacies not carrying the drug. The US leads research and development of new drugs and this bill will frustrate that effort. Prohibiting drugs from the market will reduce competition. Without drug transparency information this bill can't work properly. HCA has struggled to implement the transparency legislation and is not capable of implementing this bill. Reforms should be made to what consumers pay out-of-pocket at the pharmacy.
OTHER: The board should have more authority to look at other ways to control drug prices. Confidentiality should be strengthened. Physicians are concerned about how this bill will affect access to drugs provided in-clinic.