SENATE BILL REPORT
SB 5551
As of January 18, 2022
Title: An act relating to medicaid coverage for HIV antiviral drugs.
Brief Description: Concerning medicaid coverage for HIV antiviral drugs.
Sponsors: Senators Randall, Liias, Billig, Das, Dhingra, Frockt, Keiser, Lovelett, Lovick, Mullet, Nguyen, Pedersen, Salda?a, Stanford, Trudeau and Wilson, C..
Brief History:
Committee Activity: Health & Long Term Care: 1/19/22.
Brief Summary of Bill
  • Requires Apple Health to cover all Food and Drug Administration approved HIV antiviral drugs without prior authorization.
SENATE COMMITTEE ON HEALTH & LONG TERM CARE
Staff: LeighBeth Merrick (786-7445)
Background:

The Health Care Authority (HCA) administers the Medicaid program, which is a state-federal program that pays for health care for low-income state residents who meet certain eligibility criteria.  Washington's Medicaid program, known as Apple Health, offers a complete medical benefits package, including prescription drug coverage, to eligible families, children under age 19, low-income adults, certain disabled individuals, and pregnant women.

 

Federal law requires state Medicaid programs to cover all Food and Drug Administration (FDA) approved medications from manufacturers that have entered into the Medicaid Drug Rebate Program.  States are allowed to take certain measures to contain drug costs and utilization.  These measures include establishing a preferred drug list and requiring prior authorization.  In 2018, HCA implemented a preferred drug list (PDL) which details the Medicaid coverage requirements for each drug within a therapeutic class.  The state's Pharmacy and Therapeutics (P&T) Committee evaluates the available evidence regarding the relative safety, efficacy and effectiveness of prescription drugs in a class, and makes recommendations to HCA about which drugs should be classified as preferred.  The majority of HIV antiviral drugs on the PDL are classified as preferred and are automatically covered by Apple Health.  Before Apple Health will cover a non-preferred HIV antiviral drug, the health care provider must submit a prior authorization request to HCA explaining why the non-preferred drug is medically necessary for the patient.  Apple Health will cover the non-preferred drug once HCA approves the prior authorization request.  

 

In 2021, the Legislature directed the LGBTQ Commission to work with stakeholders to develop recommendations regarding access to HIV antiviral drugs, including eliminating Apple Health's prior authorization requirements.  The LGBTQ Commission's report with recommendations was released in November.
Summary of Bill:

Beginning January 1, 2023, Apple Health must cover all FDA approved HIV antiviral drugs without prior authorization.
Appropriation: None.
Fiscal Note: Requested on January 10, 2022.
Creates Committee/Commission/Task Force that includes Legislative members: No.
Effective Date: Ninety days after adjournment of session in which bill is passed.