PRESCRIPTION DRUG AFFORDABILITY BOARD

RCW 70.405

in effect

RCW 70.405.010 Definitions.

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise. (1) "Authority" means the health care authority. (2) "Biological product" has the same meaning as in 42 U.S.C. Sec. 262(i)(1). (3) "Biosimilar" has the same meaning as in 42 U.S.C. Sec. 262(i)(2). (4) "Board" means the prescription drug affordability board. (5) "Excess costs" means: (a) Costs of appropriate utilization of a prescription drug that exceed the therapeutic benefit relative to other alternative treatments; or (b) Costs of appropriate utilization of a prescription drug that are not sustainable to public and private health care systems over a 10-year time frame. (6) "Generic drug" has the same meaning as in RCW 69.48.020 . (7) "Health carrier" or "carrier" has the same meaning as in RCW 48.43.005 . (8) "Manufacturer" means a person, corporation, or other entity engaged in the manufacture of prescription drugs sold in or into Washington state. "Manufacturer" does not include a private label distributor or retail pharmacy that sells a drug under the retail pharmacy's store, or a prescription drug repackager. (9) "Prescription drug" means a drug regulated under chapter 69.41 or 69.50 RCW, including generic, brand name, specialty drugs, and biological products. The definitions in this section apply throughout this chapter unless the context clearly requires otherwise. (1) "Authority" means the health care authority. (2) "Biological product" has the same meaning as in 42 U.S.C. Sec. 262(i)(1). (3) "Biosimilar" has the same meaning as in 42 U.S.C. Sec. 262(i)(2). (4) "Board" means the prescription drug affordability board. (5) "Excess costs" means: (a) Costs of appropriate utilization of a prescription drug that exceed the therapeutic benefit relative to other alternative treatments; or (b) Costs of appropriate utilization of a prescription drug that are not sustainable to public and private health care systems over a 10-year time frame. (6) "Generic drug" has the same meaning as in RCW 69.48.020 . (7) "Health carrier" or "carrier" has the same meaning as in RCW 48.43.005 . (8) "Manufacturer" means a person, corporation, or other entity engaged in the manufacture of prescription drugs sold in or into Washington state. "Manufacturer" does not include a private label distributor or retail pharmacy that sells a drug under the retail pharmacy's store, or a prescription drug repackager. (9) "Prescription drug" means a drug regulated under chapter 69.41 or 69.50 RCW, including generic, brand name, specialty drugs, and biological products.

RCW 70.405.020 Prescription drug affordability board.

(1) The prescription drug affordability board is established, to include five members who have expertise in health care economics or clinical medicine appointed by the governor. (2) Board members shall serve for a term of five years and members may be reappointed by the governor for additional terms. (3) No board member or advisory group member may be an employee of, a board member of, or consultant to a prescription drug manufacturer, pharmacy benefit manager, health carrier, prescription drug wholesale distributor, or related trade association, except that a representative from the prescription drug industry serving on an advisory group may be an employee, consultant, or board member of a prescription drug manufacturer or related trade association and shall not be deemed to have a conflict of interest pursuant to subsection (4) of this section. (4)(a) Board members, advisory group members, staff members, and contractors providing services on behalf of the board shall recuse themselves from any board activity in any case in which they have a conflict of interest. (b) For the purposes of this section, a conflict of interest means an association, including a financial or personal association, that has the potential to bias or appear to bias an individual's decisions in matters related to the board or the activities of the board. (5) The board shall establish advisory groups consisting of relevant stakeholders, including but not limited to patients and patient advocates for the condition treated by the drug and one member who is a representative of the prescription drug industry, for each drug affordability review conducted by the board pursuant to RCW 70.405.040 . Advisory group members are immune from civil liability for any official act performed in good faith as a member of the group. (6) The authority shall provide administrative support to the board and any advisory group of the board and shall adopt rules governing their operation that shall include how and when the board will use and discuss confidential information that is exempt from public disclosure. The rules adopted under this subsection may not go into effect until at least 90 days after the next regular legislative session. (7) Board members shall be compensated for participation in the work of the board in accordance with a personal services contract to be executed after appointment and before commencement of activities related to the work of the board. (8) A simple majority of the board's membership constitutes a quorum for the purpose of conducting business. (9) All meetings of the board must be open and public, except that the board may hold executive sessions to the extent permitted by chapter 42.30 RCW. (10) The board may not hold its first meeting until at least one year after the authority publishes its first report on the impact that drug costs, rebates, and other discounts have on health care premiums pursuant to RCW 43.71C.100 . (11) The board must coordinate and collaborate with the authority, other boards, work groups, and commissions related to prescription drug costs and emerging therapies, including but not limited to the health care cost transparency board established in chapter 70.390 RCW, and the universal health care commission established in RCW 41.05.840 . All coordination and collaboration by the board pursuant to this subsection must comply with chapter 42.30 RCW, the open public meetings act. (12) The board may collaborate with prescription drug affordability boards established in other states. (1) The prescription drug affordability board is established, to include five members who have expertise in health care economics or clinical medicine appointed by the governor. (2) Board members shall serve for a term of five years and members may be reappointed by the governor for additional terms. (3) No board member or advisory group member may be an employee of, a board member of, or consultant to a prescription drug manufacturer, pharmacy benefit manager, health carrier, prescription drug wholesale distributor, or related trade association, except that a representative from the prescription drug industry serving on an advisory group may be an employee, consultant, or board member of a prescription drug manufacturer or related trade association and shall not be deemed to have a conflict of interest pursuant to subsection (4) of this section. (4)(a) Board members, advisory group members, staff members, and contractors providing services on behalf of the board shall recuse themselves from any board activity in any case in which they have a conflict of interest. (b) For the purposes of this section, a conflict of interest means an association, including a financial or personal association, that has the potential to bias or appear to bias an individual's decisions in matters related to the board or the activities of the board. (5) The board shall establish advisory groups consisting of relevant stakeholders, including but not limited to patients and patient advocates for the condition treated by the drug and one member who is a representative of the prescription drug industry, for each drug affordability review conducted by the board pursuant to RCW 70.405.040 . Advisory group members are immune from civil liability for any official act performed in good faith as a member of the group. (6) The authority shall provide administrative support to the board and any advisory group of the board and shall adopt rules governing their operation that shall include how and when the board will use and discuss confidential information that is exempt from public disclosure. The rules adopted under this subsection may not go into effect until at least 90 days after the next regular legislative session. (7) Board members shall be compensated for participation in the work of the board in accordance with a personal services contract to be executed after appointment and before commencement of activities related to the work of the board. (8) A simple majority of the board's membership constitutes a quorum for the purpose of conducting business. (9) All meetings of the board must be open and public, except that the board may hold executive sessions to the extent permitted by chapter 42.30 RCW. (10) The board may not hold its first meeting until at least one year after the authority publishes its first report on the impact that drug costs, rebates, and other discounts have on health care premiums pursuant to RCW 43.71C.100 . (11) The board must coordinate and collaborate with the authority, other boards, work groups, and commissions related to prescription drug costs and emerging therapies, including but not limited to the health care cost transparency board established in chapter 70.390 RCW, and the universal health care commission established in RCW 41.05.840 . All coordination and collaboration by the board pursuant to this subsection must comply with chapter 42.30 RCW, the open public meetings act. (12) The board may collaborate with prescription drug affordability boards established in other states.

RCW 70.405.030 Authority to review drug prices.

By June 30, 2023, and annually thereafter, utilizing data collected pursuant to chapters 43.71C , 43.371, and 70.390 RCW, or other data deemed relevant by the board, the board must identify prescription drugs that have been on the market for at least seven years, are dispensed at a retail, specialty, or mail-order pharmacy, are not designated by the United States food and drug administration under 21 U.S.C. Sec. 360bb as a drug solely for the treatment of a rare disease or condition, and meet the following thresholds: (1) Brand name prescription drugs and biologic products that: (a) Have a wholesale acquisition cost of $60,000 or more per year or course of treatment lasting less than one year; or (b) Have a price increase of 15 percent or more in any 12-month period or for a course of treatment lasting less than 12 months, or a 50 percent cumulative increase over three years; (2) A biosimilar product with an initial wholesale acquisition cost that is not at least 15 percent lower than the reference biological product; and (3) Generic drugs with a wholesale acquisition cost of $100 or more for a 30-day supply or less that has increased in price by 200 percent or more in the preceding 12 months. By June 30, 2023, and annually thereafter, utilizing data collected pursuant to chapters 43.71C , 43.371, and 70.390 RCW, or other data deemed relevant by the board, the board must identify prescription drugs that have been on the market for at least seven years, are dispensed at a retail, specialty, or mail-order pharmacy, are not designated by the United States food and drug administration under 21 U.S.C. Sec. 360bb as a drug solely for the treatment of a rare disease or condition, and meet the following thresholds: (1) Brand name prescription drugs and biologic products that: (a) Have a wholesale acquisition cost of $60,000 or more per year or course of treatment lasting less than one year; or (b) Have a price increase of 15 percent or more in any 12-month period or for a course of treatment lasting less than 12 months, or a 50 percent cumulative increase over three years; (2) A biosimilar product with an initial wholesale acquisition cost that is not at least 15 percent lower than the reference biological product; and (3) Generic drugs with a wholesale acquisition cost of $100 or more for a 30-day supply or less that has increased in price by 200 percent or more in the preceding 12 months.

RCW 70.405.040 Affordability reviews.

(1) The board may choose to conduct an affordability review of up to 24 prescription drugs per year identified pursuant to RCW 70.405.030 . When deciding whether to conduct a review, the board shall consider: (a) The class of the prescription drug and whether any therapeutically equivalent prescription drugs are available for sale; (b) Input from relevant advisory groups established pursuant to RCW 70.405.020 ; and (c) The average patient's out-of-pocket cost for the drug. (2) For prescription drugs chosen for an affordability review, the board must determine whether the prescription drug has led or will lead to excess costs to patients. The board may examine publicly available information as well as collect confidential and proprietary information from the prescription drug manufacturer and other relevant sources. (3) A manufacturer must submit all requested information to the board within 30 days of the request. (4) The authority may assess a fine of up to $100,000 against a manufacturer for each failure to comply with an information request from the board. The process for the assessment of a fine under this subsection shall be established by the authority in rule and is subject to review under the administrative procedure act, chapter 34.05 RCW. The rules adopted under this subsection may not go into effect until at least 90 days after the next regular legislative session. (5) When conducting a review, the board shall consider: (a) The relevant factors contributing to the price paid for the prescription drug, including the wholesale acquisition cost, discounts, rebates, or other price concessions; (b) The average patient copay or other cost sharing for the drug; (c) The effect of the price on consumers' access to the drug in the state; (d) Orphan drug status; (e) The dollar value and accessibility of patient assistance programs offered by the manufacturer for the drug; (f) The price and availability of therapeutic alternatives; (g) Input from: (i) Patients affected by the condition or disease treated by the drug; and (ii) Individuals with medical or scientific expertise related to the condition or disease treated by the drug; (h) Any other information the drug manufacturer or other relevant entity chooses to provide; (i) The impact of pharmacy benefit manager policies on the price consumers pay for the drug; and (j) Any other relevant factors as determined by the board. (6) In performing an affordability review of a drug the board may consider the following factors: (a) Life-cycle management; (b) The average cost of the drug in the state; (c) Market competition and context; (d) Projected revenue; (e) Off-label usage of the drug; and (f) Any additional factors identified by the board. (7) All information collected by the board pursuant to this section is confidential and not subject to public disclosure under chapter 42.56 RCW. (8) The board shall publicize which prescription drugs are subject to an affordability review before the review begins. (1) The board may choose to conduct an affordability review of up to 24 prescription drugs per year identified pursuant to RCW 70.405.030 . When deciding whether to conduct a review, the board shall consider: (a) The class of the prescription drug and whether any therapeutically equivalent prescription drugs are available for sale; (b) Input from relevant advisory groups established pursuant to RCW 70.405.020 ; and (c) The average patient's out-of-pocket cost for the drug. (2) For prescription drugs chosen for an affordability review, the board must determine whether the prescription drug has led or will lead to excess costs to patients. The board may examine publicly available information as well as collect confidential and proprietary information from the prescription drug manufacturer and other relevant sources. (3) A manufacturer must submit all requested information to the board within 30 days of the request. (4) The authority may assess a fine of up to $100,000 against a manufacturer for each failure to comply with an information request from the board. The process for the assessment of a fine under this subsection shall be established by the authority in rule and is subject to review under the administrative procedure act, chapter 34.05 RCW. The rules adopted under this subsection may not go into effect until at least 90 days after the next regular legislative session. (5) When conducting a review, the board shall consider: (a) The relevant factors contributing to the price paid for the prescription drug, including the wholesale acquisition cost, discounts, rebates, or other price concessions; (b) The average patient copay or other cost sharing for the drug; (c) The effect of the price on consumers' access to the drug in the state; (d) Orphan drug status; (e) The dollar value and accessibility of patient assistance programs offered by the manufacturer for the drug; (f) The price and availability of therapeutic alternatives; (g) Input from: (i) Patients affected by the condition or disease treated by the drug; and (ii) Individuals with medical or scientific expertise related to the condition or disease treated by the drug; (h) Any other information the drug manufacturer or other relevant entity chooses to provide; (i) The impact of pharmacy benefit manager policies on the price consumers pay for the drug; and (j) Any other relevant factors as determined by the board. (6) In performing an affordability review of a drug the board may consider the following factors: (a) Life-cycle management; (b) The average cost of the drug in the state; (c) Market competition and context; (d) Projected revenue; (e) Off-label usage of the drug; and (f) Any additional factors identified by the board. (7) All information collected by the board pursuant to this section is confidential and not subject to public disclosure under chapter 42.56 RCW. (8) The board shall publicize which prescription drugs are subject to an affordability review before the review begins.

RCW 70.405.050 Upper payment limits.

(1) The authority must adopt rules setting forth a methodology established by the board for setting upper payment limits for prescription drugs the board has determined have led or will lead to excess costs based on its affordability review. The rules adopted under this subsection may not go into effect until at least 90 days after the next regular legislative session. Each year, the board may set an upper payment limit for up to 12 prescription drugs. (2) The methodology must take into consideration: (a) The cost of administering the drug; (b) The cost of delivering the drug to patients; (c) The status of the drug on the drug shortage list published by the United States food and drug administration; and (d) Other relevant administrative costs related to the production and delivery of the drug. (3) The methodology determined by the board must not use quality-adjusted life years that take into account a patient's age or severity of illness or disability to identify subpopulations for which a prescription drug would be less cost-effective. For any prescription drug that extends life, the board's analysis of cost-effectiveness may not employ a measure or metric which assigns a reduced value to the life extension provided by a treatment based on a preexisting disability or chronic health condition of the individuals whom the treatment would benefit. (4) Before setting an upper payment limit for a drug, the board must post notice of the proposed upper payment limit on the authority's website, including an explanation of the factors considered when setting the proposed limit and instructions to submit written comment. The board must provide 30 days to submit public comment. (5) The board must monitor the supply of drugs for which it sets an upper payment limit and may suspend that limit if there is a shortage of the drug in the state. (6) An upper payment limit for a prescription drug established by the board applies to all purchases of the drug by any entity and reimbursements for a claim for the drug by a health carrier, or a health plan offered under chapter 41.05 RCW, when the drug is dispensed or administered to an individual in the state in person, by mail, or by other means. (7) An employer-sponsored self-funded plan may elect to be subject to the upper payment limits as established by the board. (8) The board must establish an effective date for each upper payment limit, provided that the upper payment limit may not go into effect until at least 90 days after the next regular legislative session and that the date is at least six months after the adoption of the upper payment limit and applies only to purchases, contracts, and plans that are issued on or renewed after the effective date. (9) Any entity affected by a decision of the board may request an appeal within 30 days of the board's decision, and the board must rule on the appeal within 60 days. Board rulings are subject to judicial review pursuant to chapter 34.05 RCW. (10) For any upper payment limit set by the board, the board must notify the manufacturer of the drug and the manufacturer must inform the board if it is able to make the drug available for sale in the state and include a rationale for its decision. The board must annually report to the relevant committees of the legislature detailing the manufacturers' responses. (11) The board may reassess the upper payment limit for any drug annually based on current economic factors. (12) The board may not establish an upper payment limit for any prescription drug before January 1, 2027. (13)(a) Any individual denied coverage by a health carrier for a prescription drug because the drug was unavailable due to an upper payment limit established by the board, may seek review of the denial pursuant to RCW 48.43.530 and 48.43.535 . (b) If it is determined that the prescription drug should be covered based on medical necessity, the carrier may disregard the upper payment limit and must provide coverage for the drug. (1) The authority must adopt rules setting forth a methodology established by the board for setting upper payment limits for prescription drugs the board has determined have led or will lead to excess costs based on its affordability review. The rules adopted under this subsection may not go into effect until at least 90 days after the next regular legislative session. Each year, the board may set an upper payment limit for up to 12 prescription drugs. (2) The methodology must take into consideration: (a) The cost of administering the drug; (b) The cost of delivering the drug to patients; (c) The status of the drug on the drug shortage list published by the United States food and drug administration; and (d) Other relevant administrative costs related to the production and delivery of the drug. (3) The methodology determined by the board must not use quality-adjusted life years that take into account a patient's age or severity of illness or disability to identify subpopulations for which a prescription drug would be less cost-effective. For any prescription drug that extends life, the board's analysis of cost-effectiveness may not employ a measure or metric which assigns a reduced value to the life extension provided by a treatment based on a preexisting disability or chronic health condition of the individuals whom the treatment would benefit. (4) Before setting an upper payment limit for a drug, the board must post notice of the proposed upper payment limit on the authority's website, including an explanation of the factors considered when setting the proposed limit and instructions to submit written comment. The board must provide 30 days to submit public comment. (5) The board must monitor the supply of drugs for which it sets an upper payment limit and may suspend that limit if there is a shortage of the drug in the state. (6) An upper payment limit for a prescription drug established by the board applies to all purchases of the drug by any entity and reimbursements for a claim for the drug by a health carrier, or a health plan offered under chapter 41.05 RCW, when the drug is dispensed or administered to an individual in the state in person, by mail, or by other means. (7) An employer-sponsored self-funded plan may elect to be subject to the upper payment limits as established by the board. (8) The board must establish an effective date for each upper payment limit, provided that the upper payment limit may not go into effect until at least 90 days after the next regular legislative session and that the date is at least six months after the adoption of the upper payment limit and applies only to purchases, contracts, and plans that are issued on or renewed after the effective date. (9) Any entity affected by a decision of the board may request an appeal within 30 days of the board's decision, and the board must rule on the appeal within 60 days. Board rulings are subject to judicial review pursuant to chapter 34.05 RCW. (10) For any upper payment limit set by the board, the board must notify the manufacturer of the drug and the manufacturer must inform the board if it is able to make the drug available for sale in the state and include a rationale for its decision. The board must annually report to the relevant committees of the legislature detailing the manufacturers' responses. (11) The board may reassess the upper payment limit for any drug annually based on current economic factors. (12) The board may not establish an upper payment limit for any prescription drug before January 1, 2027. (13)(a) Any individual denied coverage by a health carrier for a prescription drug because the drug was unavailable due to an upper payment limit established by the board, may seek review of the denial pursuant to RCW 48.43.530 and 48.43.535 . (b) If it is determined that the prescription drug should be covered based on medical necessity, the carrier may disregard the upper payment limit and must provide coverage for the drug.

RCW 70.405.060 Use of savings.

(1) Any savings generated for a health plan, as defined in RCW 48.43.005 , or a health plan offered under chapter 41.05 RCW that are attributable to the establishment of an upper payment limit established by the board must be used to reduce costs to consumers, prioritizing the reduction of out-of-pocket costs for prescription drugs. (2) By January 1, 2024, the board must establish a formula for calculating savings for the purpose of complying with this section. (3) By March 1st of the year following the effective date of the first upper payment limit, and annually thereafter, each state agency and health carrier issuing a health plan in the state must submit a report to the board describing the savings in the previous calendar year that were attributable to upper payment limits set by the board and how the savings were used to satisfy the requirements of subsection (1) of this section. (1) Any savings generated for a health plan, as defined in RCW 48.43.005 , or a health plan offered under chapter 41.05 RCW that are attributable to the establishment of an upper payment limit established by the board must be used to reduce costs to consumers, prioritizing the reduction of out-of-pocket costs for prescription drugs. (2) By January 1, 2024, the board must establish a formula for calculating savings for the purpose of complying with this section. (3) By March 1st of the year following the effective date of the first upper payment limit, and annually thereafter, each state agency and health carrier issuing a health plan in the state must submit a report to the board describing the savings in the previous calendar year that were attributable to upper payment limits set by the board and how the savings were used to satisfy the requirements of subsection (1) of this section.

RCW 70.405.070 Manufacturer withdrawal from the market.

(1) Any manufacturer that intends to withdraw a prescription drug from sale or distribution within the state because the board has established an upper payment limit for that drug shall provide a notice of withdrawal in writing indicating the drug will be withdrawn because of the establishment of the upper payment limit at least 180 days before the withdrawal to the office of the insurance commissioner, the authority, and any entity in the state with which the manufacturer has a contract for the sale or distribution of the drug. (2) If a manufacturer chooses to withdraw the prescription drug from the state, it shall be prohibited from selling that drug in the state for a period of three years. (3) A manufacturer that has withdrawn a drug from the market may petition the authority, in a form and manner determined by the authority in rule, to reenter the market before the expiration of the three-year ban if it agrees to make the drug available for sale in compliance with the upper payment limit. (4) The rules adopted under this section may not go into effect until at least 90 days after the next regular legislative session. (1) Any manufacturer that intends to withdraw a prescription drug from sale or distribution within the state because the board has established an upper payment limit for that drug shall provide a notice of withdrawal in writing indicating the drug will be withdrawn because of the establishment of the upper payment limit at least 180 days before the withdrawal to the office of the insurance commissioner, the authority, and any entity in the state with which the manufacturer has a contract for the sale or distribution of the drug. (2) If a manufacturer chooses to withdraw the prescription drug from the state, it shall be prohibited from selling that drug in the state for a period of three years. (3) A manufacturer that has withdrawn a drug from the market may petition the authority, in a form and manner determined by the authority in rule, to reenter the market before the expiration of the three-year ban if it agrees to make the drug available for sale in compliance with the upper payment limit. (4) The rules adopted under this section may not go into effect until at least 90 days after the next regular legislative session.

RCW 70.405.080 Reporting.

By December 15, 2022, and annually thereafter, the board shall provide a comprehensive report to the legislature detailing all actions the board has taken in the past year, including any rules adopted by the authority pursuant to chapter 153, Laws of 2022, establishing any processes, such as the methodology for the upper payment limit, the list of drugs identified in RCW 70.405.030 , the drugs the board completed an affordability review of and any determinations of whether the drug had led or will lead to excess costs, and the establishment of any upper payment limits. By December 15, 2022, and annually thereafter, the board shall provide a comprehensive report to the legislature detailing all actions the board has taken in the past year, including any rules adopted by the authority pursuant to chapter 153, Laws of 2022, establishing any processes, such as the methodology for the upper payment limit, the list of drugs identified in RCW 70.405.030 , the drugs the board completed an affordability review of and any determinations of whether the drug had led or will lead to excess costs, and the establishment of any upper payment limits.

RCW 70.405.090 Rule making.

The authority may adopt any rules necessary to implement this chapter. The rules adopted under this section may not go into effect until at least 90 days after the next regular legislative session. The authority may adopt any rules necessary to implement this chapter. The rules adopted under this section may not go into effect until at least 90 days after the next regular legislative session.

Source: WA Statutes (Official Site)URL: https://app.leg.wa.gov/RCW/default.aspx?cite=70.405&full=trueFetched: 6/29/2026