Denial of Prescribed Pharmaceuticals

The WSMA encourages state payers of medical services to cover physician-prescribed pharmaceuticals unless a state-physician review provides evidence that a substitution is equivalent, safe and cost effective. (Res B-1, A-08)

The WSMA believes that if prerequisites for coverage are established by state payers, the burden of proof is on the payers to assure that such prerequisites are paid for and demonstrated available to the insured within 20 business days of any denial. (Res B-1, A-08)

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Abbreviations for House of Delegates report origination:

EC – Executive Committee; BT – Board of Trustees; CPA – Council on Professional Affairs; JC – Judicial Council; CHS – Community and Health Services