State Law

Revised Code of Washington-Title 48-Chapter 48.43. Insurance Reform

08/26/2023 Washington Section 48.43.400

Prescription drug utilization management — Definitions

Medical Necessity-Definition, U.R. Criteria

The definitions in this section apply throughout this section and RCW 48.43.410 and 48.43.420 unless the context clearly requires otherwise.

(1) “Clinical practice guidelines” means a systemically developed statement to assist decision making by health care providers and patients about appropriate health care for specific clinical circumstances and conditions.

U.R. Criteria

(2) “Clinical review criteria” means the written screening procedures, decision rules, medical protocols, and clinical practice guidelines used by a health carrier or prescription drug utilization management entity as an element in the evaluation of medical necessity and appropriateness of requested prescription drugs under a health plan.

(3) “Emergency fill” means a limited dispensed amount of medication that allows time for the processing of prescription drug utilization management.

Medical Necessity-Definition

(4) “Medically appropriate” means prescription drugs that under the applicable standard of care are appropriate: (a) To improve or preserve health, life, or function; (b) to slow the deterioration of health, life, or function; or (c) for the early screening, prevention, evaluation, diagnosis, or treatment of a disease, condition, illness, or injury.

(5) “Prescription drug utilization management” means a set of formal techniques used by a health carrier or prescription drug utilization management entity, that are designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy, or efficiency of prescription drugs including, but not limited to, prior authorization and step therapy protocols.

(6) “Prescription drug utilization management entity” means an entity affiliated with, under contract with, or acting on behalf of a health carrier to perform prescription drug utilization management.

(7) “Prior authorization” means a mandatory process that a carrier or prescription drug utilization management entity requires a provider or facility to follow to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan.

(8) “Step therapy protocol” means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition will be covered by a health carrier.