Advocacy Briefs

Washington State Legislature Moves to Address Medicaid Drug Access and creates STI/PrEP/PEP Workgroup

In Washington state (WA), a collective sense of relief was felt when the session’s final gavel came down on April 30th.  

Before the start of the session in January, legislative leadership—with Democrats in control of both the House and Senate—had outlined clear expectations on what they were hoping to accomplish this session. Focusing on caucus priorities, they looked to pandemic recovery, police accountability, climate, housing, and working to address the Health Care Authority’s (WA HCA) more restrictive state Medicaid (Apple Health) HIV formulary.  

Currently, in WA, “new-to-market” drugs included in the HIV antiviral class (on the Apple Health Preferred Drug List) are non-preferred and subject to prior authorization criteria, as outlined in Medical Policy No. 12.10.99-2. 

It states that: “Non-preferred agents in that class require an inadequate response or documented intolerance due to severe adverse reaction or contraindication to at least one preferred regimen. If a drug within this policy receives a new indication approved by the Food and Drug Administration (FDA), medical necessity for the new indication will be determined on a case-by-case basis following FDA labeling.”

“If all criteria are not met, but there are documented medically necessary or situational circumstances, based on the professional judgment of the clinical reviewer, requests may be approved on a case-by-case basis up to the initial authorization duration.”

“Clients new to Apple Health or new to a Managed Care Organization (MCO), who are requesting regimens for the continuation of therapy should be reviewed following the reauthorization criteria [as] listed.”

But providers and advocates alike, like those in the Washington HIV Justice Alliance (WHJA), had long argued that when the state moved towards more restrictive utilization management protocols for HIV medications (July 2017), it ignored Governor Inslee’s 2014 proclamation to end the incidence of HIV in Washington. They argue that the protocol restricts rather than expands HIV medication access and utilization, or provider choice—a bedrock of trust between providers and their patients. 

Dr. Peter Shalit, a private practice physician in Seattle and Clinical Professor of Medicine at the University of Washington, who’s been caring for people with HIV since 1990, wrote in the Seattle Times (12/2020), “[t]hat providers may not be able to prescribe what they think is the best treatment option, instead of starting with what they feel is an inferior regimen. The physician must then monitor the ineffectiveness of that treatment to justify to the state why their patient should instead be prescribed a “non-preferred” (that is, more expensive) therapy.”

By qualifying for the program, people with HIV who have Medicaid coverage are low income and have significant existing barriers to care.

“The entire rationale for expanding the Medicaid program under the Patient Protection and Affordable Care Act,” Lauren Fanning of the WHJA states, “was meant to combine both aspects of those federal considerations equally—protections and affordability.” 

Erick Seelbach, ED for Pierce County AIDS Foundation (or PCAF), agrees. “It’s not simply an issue of cost; it’s a ‘fail first’ mentality that puts patients at greater risk of reduced adherence.”

Treatment for HIV has evolved rapidly over the years—and continues on that path with even more innovative meds like injectables and gene therapies. Yet, these therapeutics are often more costly than their “older” counterparts. The Department of Health and Human Services (DHHS) HIV Treatment Guidelines—widely recognized by the medical community as setting the current standard for HIV treatment—has reviewed and recommended for use all of the drugs that are considered “non-preferred” on the Apple Health formulary. 

With that in mind, the WHJA made legislative hay in the state’s operating budget in an effort to examine and develop recommendations regarding changes to the Medicaid drug formulary—including short-and long-term fiscal implications of eliminating current prior authorization and fail-first requirements; the impact of drug access on public health; and the statewide goal of reducing HIV transmissions. 

The Washington State LGBTQ Commission will lead that work, in collaboration with the state’s HCA, its Department of Health, statewide advocates, and Medicaid physicians to issue a report on its findings by November 1st, 2021.

The legislature also went one step further in providing funds for an STI, PrEP, and PEP workgroup to make recommendations concerning funding and policy initiatives to address the spread of sexually transmitted infections in WA. 

Governor Inslee will soon appoint the equity-focused workgroup. The workgroup is mandated to submit a report to the legislature by December 1st, 2022. Recommendations will be looking at ways the state can eradicate congenital syphilis and hepatitis B by 2030; control the spread of gonorrhea, syphilis, and chlamydia; end the need for confirmatory syphilis testing by the public health laboratory, and expand access to PrEP and PEP.

-Scott Bertani, Director of Advocacy

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