Washington Code 48.46.510 – Phenylketonuria
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(1) The legislature finds that:
Terms Used In Washington Code 48.46.510
- Commissioner: means the insurance commissioner. See Washington Code 48.46.020
- Contract: A legal written agreement that becomes binding when signed.
- Deductible: means the amount an enrolled participant is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment. See Washington Code 48.46.020
- Health maintenance organization: means any organization receiving a certificate of registration by the commissioner under this chapter which provides comprehensive health care services to enrolled participants of such organization on a group practice per capita prepayment basis or on a prepaid individual practice plan, except for an enrolled participant's responsibility for copayments and/or deductibles, either directly or through contractual or other arrangements with other institutions, entities, or persons, and which qualifies as a health maintenance organization pursuant to RCW 48. See Washington Code 48.46.020
(a) Phenylketonuria is a rare inherited genetic disorder.
(b) Children with phenylketonuria are unable to metabolize an essential amino acid, phenylalanine, which is found in the proteins of most food.
(c) To remain healthy, children with phenylketonuria must maintain a strict diet and ingest a mineral and vitamin-enriched formula.
(d) Children who do not maintain their diets with the formula acquire severe mental and physical difficulties.
(e) Originally, the formulas were listed as prescription drugs but were reclassified as medical foods to increase their availability.
(2) Subject to requirements and exceptions which may be established by rules adopted by the commissioner, any agreement for health care services delivered or issued for delivery or renewed in this state on or after September 1, 1988, shall provide coverage for the formulas necessary for the treatment of phenylketonuria. Such formulas shall be covered when deemed medically necessary by the medical director or his or her designee of the health maintenance organization and if provided by the health maintenance organization or upon the health maintenance organization’s referral. Formulas shall be covered at the usual and customary rates for such formulas, subject to contract provisions with respect to deductible amounts or copayments.
[ 1988 c 173 § 4.]