HEALTH CARE AUTHORITY

[Filed March 4, 2020, 8:39 a.m., effective April 4, 2020]

Effective Date of Rule: Thirty-one days after filing.

Purpose: The agency revised this rule to comply with the requirements of section 1004 of the Support for Patients and Communities Act under 42 U.S.C. 1396a(a) by more accurately detailing the drug use review (DUR) activities to include reference to prior authorization requirements adding subsection (1)(a)(iv) and (2)(c) and include the activities of prescribing practitioners in addition to dispensing pharmacies in subsection (2) and (2)(b). The agency also revised subsection (1)(b) to update language in accordance with the Support Act including prescribing billing practices that indicate abuse or excessive utilization.

Citation of Rules Affected by this Order: Amending WAC 182-530-4050.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160, H.R. 6, Section 1004, 42 U.S.C. 1396a(a), 42 U.S.C. 1396r-8(g).

Adopted under notice filed as WSR 20-02-078 on December 27, 2019.

Changes Other than Editing from Proposed to Adopted Version:

WAC 180-530-4050 (1)(a)(iv)
Proposed	Obtain authorization prior to dispensing when required by the agency or an agency designee.
Adopted	Obtain authorization as described in WAC 182-530-3200 prior to dispensing when required by the agency or an agency designee.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: March 4, 2020.

AMENDATORY SECTION(Amending WSR 16-01-046, filed 12/9/15, effective 1/9/16)

WAC 182-530-4050Drug use and claims review.

(1) The agency's drug use review (DUR) consists of:

(a) A prospective drug use review (Pro-DUR) that requires all pharmacy providers to:

(i) Obtain patient histories of allergies, idiosyncrasies, or chronic condition or conditions which may relate to drug utilization;

(ii) Screen for potential drug therapy problems; ((and))

(iii) Counsel the patient in accordance with existing state pharmacy laws and federal regulations; and

(iv) Obtain authorization as described in WAC 182-530-3200 prior to dispensing when required by the agency or an agency designee.

(b) A retrospective drug use review (Retro-DUR), in which the agency provides for the ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, ((or))excessive utilization, inappropriate or medically unnecessary care, or prescribing billing practices that indicate abuse or excessive utilization among physicians, pharmacists, and individuals receiving benefits.

(2) The agency reviews a periodic sampling of claims to determine if drugs are appropriately ordered, prescribed, administered, dispensed, and billed. If a review of the sample finds that a provider is inappropriately ordering, prescribing, administering, dispensing, or billing for drugs, the agency may implement corrective action that includes, but is not limited to:

(a) Educating the provider regarding the problem practice or practices;

(b) Requiring the provider to maintain specific documentation in addition to the normal documentation requirements regarding the provider's ordering, prescribing, administering, dispensing, or billing ((actions))practices;

(c) Applying additional provider-specific requirements for obtaining authorization prior to ordering, prescribing, administering, dispensing, or billing for drugs;

(d) Recouping the payment for the drug or drugs; or

(((d)))(e) Terminating the provider's core provider agreement (CPA).