The Health Care Authority (Authority) 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. Medicaid eligibility is based upon income or a combination of income and other criteria such as age, disability, or pregnancy. Medicaid benefits cover a range of health services, provided through managed care plans or the Authority on a fee-for-service basis, including health professional services, prescription medications, hospital services, durable medical equipment, mental health services, and some dental and vision services.
For prescription drugs, the Authority maintains a single preferred drug list that is used for medical assistance programs. Both fee-for-service programs and managed care plans must use this drug list as their primary preferred drug list and follow the preferred status, authorization criteria, quantity limits, step therapy protocols, specialty drug designation, 90-day supply limit designation, and other restrictions, as established by the Authority.
Since 2018 the Authority's preferred drug list has included drugs used to treat HIV and for pre-exposure prophylaxis (PrEP). In 2020 the Authority applied a clinical policy to guide patients and providers to certain medications determined to be less costly and equally effective. The 2023-25 Operating Budget directed the Authority to cover all federal Food and Drug Administration-approved drugs used to treat HIV or for PrEP without prior authorization.
The Health Care Authority must provide coverage to enrollees in medical assistance programs for all HIV antiviral drugs approved by the federal Food and Drug Administration without prior authorization or step therapy.
(In support) This bill presents an opportunity to ensure that Washingtonians can access critical preventative drugs. This bill codifies the current policy supported by the budget to cover HIV antiviral drugs without prior authorization or step therapy. The antiviral drugs that would be permanently covered under this bill are critical components to the prevention of HIV. There are important clinical reasons for selecting one regimen over another such as drug resistance and side effects and this bill gives practitioners the full range of options to provide patients with timely access to these medications. Making sure HIV patients have access to the medications that work for them gives HIV-positive individuals the ability to manage their health care needs and is an important prevention strategy which prevents transmission by viral load suppression.
Historically marginalized communities are at disproportionate risk for HIV transmission. They are also disproportionately likely to be insured through Medicaid and unlikely to be able to afford these critical preventative measures without coverage.
(Opposed) None.
David Ramos, Cascade AIDS Project; and Katie Kolan, AIDS Healthcare Foundation.