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.

Beginning January 1, 2023, Apple Health must cover all FDA approved HIV antiviral drugs without prior authorization.

PRO:  Study after study indicates that HIV is untransmittable when HIV viral loads are undetectable.  Extending Medicaid coverage for single pill regimens helps people living with HIV adhere to their medication regimens which suppress their viral loads, keeping them healthier and unable to transmit HIV.  One in five people living with HIV in Washington are not virally suppressed.  These individuals are often from marginalized communities and face more barriers to accessing their medications.  Many of them face housing instability, behavioral health issues and may hide their medications due to the stigma associated with HIV.  This makes handling multiple pills a day a true barrier.  One in four prior authorization requests is denied.  The prior authorization process for the six restricted medications on the PDL is overly burdensome and discriminatory.  HCA does not recognize houselessness as a criteria for approving a prior authorization request.  Additionally, undocumented immigrants in Washington have unrestricted access to medications through Department of Health's Aids Drug Assistance Program, but documented U.S. citizens are not able to access the same medications through Apple Health.  Many state Medicaid programs and Medicare Part D provide low-barrier access to medications.  This bill will improve public health and reduce costs over the long-run since people will be able to access the necessary treatments.

OTHER:  The Legislature has entrusted HCA with the health care coverage responsibilities for Washington's most marginalized communities and has directed HCA to create tools to do this.  The PDL does not limit coverage.  Through the prior authorization process, HCA works with the provider to provide the drugs the patient needs.