The Washington state insurance commissioner’s office has updated the state’s prescription drug coverage rules.
The rules affect insurers’ use of “formularies,” or lists of drugs that an insurer either will cover or will cover in a way that lowers out-of-pocket costs for the patient.
One change replaces clinical trial coverage requirements with the clinical trial provision from the Patient Protection and Affordable Care Act of 2010 (PPACA). The section deals with how carriers should apply provider network rules when patients who have life-threatening conditions want to participate in clinical trials of new drugs.
Another change governs how formulary changes affect insurers’ financial performance. In the past, an insurer could not use a formulary change to increase its “underwriting gain.” The revised regulation states that an insurer can include underwriting gain in its product pricing, but that formulary changes “may not result in additional gain beyond the original pricing,” officials said in a description of the changes.
A third change will affect moves by patients and doctors to ask for coverage for off-formulary drugs through a substitution process.
The change, added at the request of insurers, confirms “the fact that the substitution process itself is not a grievance or appeal process,” officials said.
The changes are set to take effect 31 days after Oct. 8, the official filing date.