Chapter 388-530 WAC: Prescription drugs (outpatient)

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WACs > Title 388 > Chapter 388-530

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Chapter 388-530 WAC	Last Update: 2/5/09
Prescription drugs (outpatient)

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WAC Sections

388-530-1000	Outpatient drug program--General.
388-530-1050	Definitions.
388-530-1075	Requirements -- Use of tamper-resistant prescription pads.
COVERAGE
388-530-2000	Covered--Outpatient drugs, devices, and drug-related supplies.
388-530-2100	Noncovered--Outpatient drugs and pharmaceutical supplies.
AUTHORIZATION
388-530-3000	When the department requires authorization.
388-530-3100	How the department determines when a drug requires authorization.
388-530-3200	The department's authorization process.
QUALITY OF CARE
388-530-4000	Drug use review (DUR) board.
388-530-4050	Drug use and claims review.
388-530-4100	Washington preferred drug list (PDL).
388-530-4150	Therapeutic interchange program (TIP).
BILLING
388-530-5000	Billing requirements--Pharmacy claim payment.
388-530-5050	Billing requirements--Point-of-sale (POS) system/prospective drug use review (Pro-DUR).
388-530-5100	Billing requirements--Unit dose.
MAIL-ORDER SERVICES
388-530-6000	Mail-order services.
REIMBURSEMENT
388-530-7000	Reimbursement.
388-530-7050	Reimbursement--Dispensing fee determination.
388-530-7100	Reimbursement--Pharmaceutical supplies.
388-530-7150	Reimbursement--Compounded prescriptions.
388-530-7200	Reimbursement--Out-of-state prescriptions.
388-530-7250	Reimbursement--Miscellaneous.
388-530-7300	Reimbursement--Requesting a change.
388-530-7350	Reimbursement--Unit dose drug delivery systems.
388-530-7400	Reimbursement--Compliance packaging services.
388-530-7500	Drug rebate requirement.
388-530-7600	Reimbursement--Clients enrolled in managed care.
388-530-7700	Reimbursement--Dual eligible clients/medicare.
388-530-7800	Reimbursement--Clients with third-party liability.
388-530-7900	Drugs purchased under the Public Health Service (PHS) Act.
REIMBURSEMENT METHODOLOGY
388-530-8000	Reimbursement method--Estimated acquisition cost (EAC).
388-530-8050	Reimbursement--Federal upper limit (FUL).
388-530-8100	Reimbursement--Maximum allowable cost (MAC).
388-530-8150	Reimbursement--Automated maximum allowable cost (AMAC).

DISPOSITIONS OF SECTIONS FORMERLY CODIFIED IN THIS CHAPTER

388-530-1100	Covered drugs, devices, and pharmaceutical supplies. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1100, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1100, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1100, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1100, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1125	Drug rebate program. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1125, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1125, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1125, filed 12/7/00, effective 1/7/01.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1150	Noncovered drugs and pharmaceutical supplies and reimbursement limitations. [Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-530-1150, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1150, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1150, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1150, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1150, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1200	Prior authorization program. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1200, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1200, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1200, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1200, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1250	Prior authorization process. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1250, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1250, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1250, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1250, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1260	Therapeutic consultation service. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1260, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.08.090, 74.04.050. 01-24-066, § 388-530-1260, filed 11/30/01, effective 1/2/02.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1270	Mail-order services. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1270, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.08.090, 74.09.510, and 2002 c 371 (2001-03 Revised Omnibus Operating Budget - 2002 Supp.). 03-05-043, § 388-530-1270, filed 2/13/03, effective 3/16/03.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1280	Preferred drug list(s). [Statutory Authority: RCW 69.41.190, 70.14.050, and 74.08.090. 05-11-078, § 388-530-1280, filed 5/17/05, effective 6/17/05. Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1280, filed 12/30/04, effective 1/30/05.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1290	Therapeutic interchange program (TIP). [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1290, filed 12/30/04, effective 1/30/05.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1300	General reimbursement methodology. [Statutory Authority: RCW 74.08.090 and 74.09.520. 04-01-089, § 388-530-1300, filed 12/16/03, effective 1/16/04. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1300, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1300, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1300, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1350	Estimated acquisition cost (EAC) methodology. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1350, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1350, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1350, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1360	Certified average wholesale price (CAWP). [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1360, filed 8/9/02, effective 9/9/02.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1400	Maximum allowable cost (MAC) methodology. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1400, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1400, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1400, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1400, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1405	Automated maximum allowable cost (AMAC). [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1405, filed 8/9/02, effective 9/9/02.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1410	Federal upper limit (FUL) methodology. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1410, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1410, filed 12/7/00, effective 1/7/01.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1425	Payment methodology for drugs purchased under the Public Health Service (PHS) Act. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1425, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1425, filed 12/7/00, effective 1/7/01.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1450	Dispensing fee determination. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1450, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1450, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1450, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1500	Reimbursement for compounded prescriptions. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1500, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1500, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1500, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1550	Unit dose drug delivery systems. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1550, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1550, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1550, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1600	Unit dose pharmacy billing requirements. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1600, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1600, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.04.050, 74.08.090, 42 CFR 447.333 and Attachment 4.19-B, Page 2-b of the State Plan under Title XIX of the Social Security Act. 98-14-005, § 388-530-1600, filed 6/18/98, effective 7/19/98. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1600, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1625	Compliance packaging services. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1625, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1625, filed 12/7/00, effective 1/7/01.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1650	Reimbursement for pharmaceutical supplies. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1650, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1650, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1650, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1700	Drugs and drug-related supplies from nonpharmacy providers. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1700, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, § 388-530-1700, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1700, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1750	Drugs and pharmaceutical supplies for clients with any third-party coverage. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1750, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.09.035. 00-14-071, § 388-530-1750, filed 7/5/00, effective 8/5/00. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1750, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1800	Requirements for pharmacy claim payment. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1800, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-530-1800, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1800, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1850	Drug use review (DUR) board. [Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 2003 1st sp.s. c 29 § 10, 42 C.F.R. 456.716, RCW 41.05.160. 04-11-009, § 388-530-1850, filed 5/5/04, effective 6/5/04. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1850, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1850, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1850, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1900	Drug use and claims review. [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1900, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1900, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1900, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1900, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-1950	Point-of-sale (POS) system/prospective drug use review (Pro-DUR). [Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1950, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1950, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1950, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-08-018 (Order 3960), § 388-530-1950, filed 3/26/96, effective 4/26/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
388-530-2050	Reimbursement for out-of-state prescriptions. [Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-2050, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-2050, filed 12/7/00, effective 1/7/01; 00-01-088, § 388-530-2050, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-2050, filed 10/9/96, effective 11/9/96.] Repealed by 07-20-049, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.