{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.15_2.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.15_2.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.15_2.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.15_2.html"}],"law_id":81930,"edition_id":1,"section_id":81930,"structure_id":12994,"section_number":"38.2-3407.15:2","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for drug benefits","history":"2015, cc. 515, 516; 2019, c. 683; 2021, Sp. Sess. I, cc. 66, 67; 2023, cc. 474, 475; 2024, cc. 320, 338; 2025, cc. 58, 68, 284.","full_text":"A\n\nAs used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier” has the same meaning as provided in subsection A of § 38.2-3407.15.\n\t\t\t“Prior authorization” means the approval process used by a carrier before certain drug benefits may be provided.\n\t\t\t“Provider contract” has the same meaning as provided in subsection A of § 38.2-3407.15.\n\t\t\t“Supplementation” means a request communicated by the carrier to the prescriber or his designee for additional information, limited to items specifically requested on the applicable prior authorization request, necessary to approve or deny such request.B\n\nAny provider contract between a carrier and a participating health care provider with prescriptive authority, or its contracting agent, shall contain specific provisions that:1\n\nRequire the carrier to, in a method of its choosing, accept telephonic, facsimile, or electronic submission of prior authorization requests that are delivered from e-prescribing systems, electronic health record systems, and health information exchange platforms that utilize the National Council for Prescription Drug Programs’ SCRIPT standards;2\n\nRequire that the carrier communicate to the prescriber or his designee within 24 hours, including weekend hours, of submission of an urgent prior authorization request to the carrier, if submitted telephonically or in an alternate method directed by the carrier, that the request is approved, denied, or requires supplementation;3\n\nRequire that the carrier communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a fully completed prior authorization request, that the request is approved, denied, or requires supplementation;4\n\nRequire that the carrier communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a properly completed supplementation from the prescriber or his designee, that the request is approved or denied;5\n\nRequire that if a prior authorization request is approved for prescription drugs and such prescription drugs have been scheduled, provided, or delivered to the patient consistent with the authorization, the carrier shall not revoke, limit, condition, modify, or restrict that authorization unless (i) there is evidence that the authorization was obtained based on fraud or misrepresentation; (ii) final actions by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer remove the drug from the market, limit its use in a manner that affects the authorization, or communicate a patient safety issue that would affect the authorization alone or in combination with other authorizations; (iii) a combination of drugs prescribed would cause a drug interaction; or (iv) a generic or biosimilar is added to the prescription drug formulary. Nothing in this section shall require a carrier to cover any benefit not otherwise covered or cover a prescription drug if the enrollee is no longer covered by a health plan on the date the prescription drug was scheduled, provided, or delivered;6\n\nRequire that if the prior authorization request is denied, the carrier shall communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within the timeframes established by subdivision 3 or 4, as applicable, the reasons for the denial;7\n\nRequire that prior authorization approved by another carrier be honored, upon the carrier’s receipt from the prescriber or his designee of a record demonstrating the previous carrier’s prior authorization approval or any written or electronic evidence of the previous carrier’s coverage of such drug, at least for the initial 90 days of a member’s prescription drug benefit coverage under a new health plan, subject to the provisions of the new carrier’s evidence of coverage and any exception listed in subdivision 5;8\n\nRequire that a tracking system be used by the carrier for all prior authorization requests and that the identification information be provided electronically, telephonically, or by facsimile to the prescriber or his designee, upon the carrier’s response to the prior authorization request;9\n\nRequire that the carrier’s prescription drug formularies, all drug benefits subject to prior authorization by the carrier, all of the carrier’s prior authorization procedures, and all prior authorization request forms accepted by the carrier be made available through one central location on the carrier’s website and that such information be updated by the carrier within seven days of approved changes;10\n\nRequire a carrier to honor a prior authorization issued by the carrier for a drug, other than an opioid, regardless of changes in dosages of such drug, provided such drug is prescribed consistent with U.S. Food and Drug Administration-labeled dosages;11\n\nRequire a carrier to honor a prior authorization issued by the carrier for a drug regardless of whether the covered person changes plans with the same carrier and the drug is a covered benefit with the current health plan;12\n\nRequire a carrier, when requiring a prescriber to provide supplemental information that is in the covered individual’s health record or electronic health record, to identify the specific information required;13\n\nRequire that no prior authorization be required for at least one drug prescribed for substance abuse medication-assisted treatment, provided that (i) the drug is a covered benefit, (ii) the prescription does not exceed the FDA-labeled dosages, and (iii) the drug is prescribed consistent with the regulations of the Board of Medicine;14\n\nRequire that when any carrier has previously approved prior authorization for any drug prescribed for the treatment of a mental disorder listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, no additional prior authorization shall be required by the carrier, provided that (i) the drug is a covered benefit; (ii) the prescription does not exceed the FDA-labeled dosages; (iii) the prescription has been continuously issued for no fewer than three months; and (iv) the prescriber performs an annual review of the patient to evaluate the drug’s continued efficacy, changes in the patient’s health status, and potential contraindications. Nothing in this subdivision shall prohibit a carrier from requiring prior authorization for any drug that is not listed on its prescription drug formulary at the time the initial prescription for the drug is issued;15\n\nRequire a carrier to honor a prior authorization issued by the carrier for a drug regardless of whether the drug is removed from the carrier’s prescription drug formulary after the initial prescription for that drug is issued, provided that the drug and prescription are consistent with the applicable provisions of subdivision 14;16\n\nRequire a carrier, beginning July 1, 2025, notwithstanding the provisions of subdivision 1 or any other provision of this section, to establish and maintain an online process that (i) links directly to all e-prescribing systems and electronic health record systems that utilize the National Council for Prescription Drug Programs SCRIPT standard and the National Council for Prescription Drug Programs Real Time Benefit Standard; (ii) can accept electronic prior authorization requests from a provider; (iii) can approve electronic prior authorization requests (a) for which no additional information is needed by the carrier to process the prior authorization request, (b) for which no clinical review is required, and (c) that meet the carrier’s criteria for approval; (iv) links directly to real-time patient out-of-pocket costs for the prescription drug, considering copayment and deductible; and (v) otherwise meets the requirements of this section. No carrier shall (a) impose a fee or charge on any person for accessing the online process as required by this subdivision or (b) access, absent provider consent, provider data via the online process other than for the enrollee. No later than July 1, 2024, a carrier shall provide contact information of any third-party vendor or other entity the carrier will use to meet the requirements of this subdivision or the requirements of § 38.2-3407.15:7 to any provider that requests such information. A carrier that posts such contact information on its website shall be considered to have met this requirement; and17\n\nRequire a participating health care provider, beginning July 1, 2025, to ensure that any e-prescribing system or electronic health record system owned by or contracted for the provider to maintain an enrollee’s health record has the ability to access, at the point of prescribing, the electronic prior authorization process established by a carrier as required by subdivision 16 and the real-time patient-specific benefit information, including out-of-pocket costs and more affordable medication alternatives made available by a carrier pursuant to § 38.2-3407.15:7. A provider may request a waiver of compliance under this subdivision for undue hardship for a period specified by the appropriate regulatory authority with the Health and Human Resources Secretariat.C\n\nThe Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.D\n\nThis section shall apply with respect to any contract between a carrier and a participating health care provider or its contracting agent that is entered into, amended, extended, or renewed on or after January 1, 2016.E\n\nNotwithstanding any law to the contrary, the provisions of this section shall not apply to:1\n\nCoverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid), Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE);2\n\nAccident only, credit or disability insurance, long-term care insurance, TRICARE supplement, Medicare supplement, or workers’ compensation coverages;3\n\nAny dental services plan or optometric services plan as defined in § 38.2-4501; or4\n\nAny health maintenance organization that (i) contracts with one multispecialty group of physicians who are employed by and are shareholders of the multispecialty group, which multispecialty group of physicians may also contract with health care providers in the community; (ii) provides and arranges for the provision of physician services by such multispecialty group physicians or by such contracted health care providers in the community; and (iii) receives and processes at least 85 percent of prescription drug prior authorization requests in a manner that is interoperable with e-prescribing systems, electronic health records, and health information exchange platforms.","order_by":null,"text":{"0":{"id":293546,"text":"As used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier” has the same meaning as provided in subsection A of § 38.2-3407.15.\n\t\t\t“Prior authorization” means the approval process used by a carrier before certain drug benefits may be provided.\n\t\t\t“Provider contract” has the same meaning as provided in subsection A of § 38.2-3407.15.\n\t\t\t“Supplementation” means a request communicated by the carrier to the prescriber or his designee for additional information, limited to items specifically requested on the applicable prior authorization request, necessary to approve or deny such request.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":293547,"text":"Any provider contract between a carrier and a participating health care provider with prescriptive authority, or its contracting agent, shall contain specific provisions that:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":293548,"text":"Require the carrier to, in a method of its choosing, accept telephonic, facsimile, or electronic submission of prior authorization requests that are delivered from e-prescribing systems, electronic health record systems, and health information exchange platforms that utilize the National Council for Prescription Drug Programs’ SCRIPT standards;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":293549,"text":"Require that the carrier communicate to the prescriber or his designee within 24 hours, including weekend hours, of submission of an urgent prior authorization request to the carrier, if submitted telephonically or in an alternate method directed by the carrier, that the request is approved, denied, or requires supplementation;","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":293550,"text":"Require that the carrier communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a fully completed prior authorization request, that the request is approved, denied, or requires supplementation;","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"5":{"id":293551,"text":"Require that the carrier communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a properly completed supplementation from the prescriber or his designee, that the request is approved or denied;","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"B5"},"6":{"id":293552,"text":"Require that if a prior authorization request is approved for prescription drugs and such prescription drugs have been scheduled, provided, or delivered to the patient consistent with the authorization, the carrier shall not revoke, limit, condition, modify, or restrict that authorization unless (i) there is evidence that the authorization was obtained based on fraud or misrepresentation; (ii) final actions by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer remove the drug from the market, limit its use in a manner that affects the authorization, or communicate a patient safety issue that would affect the authorization alone or in combination with other authorizations; (iii) a combination of drugs prescribed would cause a drug interaction; or (iv) a generic or biosimilar is added to the prescription drug formulary. Nothing in this section shall require a carrier to cover any benefit not otherwise covered or cover a prescription drug if the enrollee is no longer covered by a health plan on the date the prescription drug was scheduled, provided, or delivered;","type":"section","prefixes":["B","5"],"prefix":"5","entire_prefix":"B5","prefix_anchor":"B5","level":2,"prior_prefix":"B4","next_prefix":"B6"},"7":{"id":293553,"text":"Require that if the prior authorization request is denied, the carrier shall communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within the timeframes established by subdivision 3 or 4, as applicable, the reasons for the denial;","type":"section","prefixes":["B","6"],"prefix":"6","entire_prefix":"B6","prefix_anchor":"B6","level":2,"prior_prefix":"B5","next_prefix":"B7"},"8":{"id":293554,"text":"Require that prior authorization approved by another carrier be honored, upon the carrier’s receipt from the prescriber or his designee of a record demonstrating the previous carrier’s prior authorization approval or any written or electronic evidence of the previous carrier’s coverage of such drug, at least for the initial 90 days of a member’s prescription drug benefit coverage under a new health plan, subject to the provisions of the new carrier’s evidence of coverage and any exception listed in subdivision 5;","type":"section","prefixes":["B","7"],"prefix":"7","entire_prefix":"B7","prefix_anchor":"B7","level":2,"prior_prefix":"B6","next_prefix":"B8"},"9":{"id":293555,"text":"Require that a tracking system be used by the carrier for all prior authorization requests and that the identification information be provided electronically, telephonically, or by facsimile to the prescriber or his designee, upon the carrier’s response to the prior authorization request;","type":"section","prefixes":["B","8"],"prefix":"8","entire_prefix":"B8","prefix_anchor":"B8","level":2,"prior_prefix":"B7","next_prefix":"B9"},"10":{"id":293556,"text":"Require that the carrier’s prescription drug formularies, all drug benefits subject to prior authorization by the carrier, all of the carrier’s prior authorization procedures, and all prior authorization request forms accepted by the carrier be made available through one central location on the carrier’s website and that such information be updated by the carrier within seven days of approved changes;","type":"section","prefixes":["B","9"],"prefix":"9","entire_prefix":"B9","prefix_anchor":"B9","level":2,"prior_prefix":"B8","next_prefix":"B10"},"11":{"id":293557,"text":"Require a carrier to honor a prior authorization issued by the carrier for a drug, other than an opioid, regardless of changes in dosages of such drug, provided such drug is prescribed consistent with U.S. Food and Drug Administration-labeled dosages;","type":"section","prefixes":["B","10"],"prefix":"10","entire_prefix":"B10","prefix_anchor":"B10","level":2,"prior_prefix":"B9","next_prefix":"B11"},"12":{"id":293558,"text":"Require a carrier to honor a prior authorization issued by the carrier for a drug regardless of whether the covered person changes plans with the same carrier and the drug is a covered benefit with the current health plan;","type":"section","prefixes":["B","11"],"prefix":"11","entire_prefix":"B11","prefix_anchor":"B11","level":2,"prior_prefix":"B10","next_prefix":"B12"},"13":{"id":293559,"text":"Require a carrier, when requiring a prescriber to provide supplemental information that is in the covered individual’s health record or electronic health record, to identify the specific information required;","type":"section","prefixes":["B","12"],"prefix":"12","entire_prefix":"B12","prefix_anchor":"B12","level":2,"prior_prefix":"B11","next_prefix":"B13"},"14":{"id":293560,"text":"Require that no prior authorization be required for at least one drug prescribed for substance abuse medication-assisted treatment, provided that (i) the drug is a covered benefit, (ii) the prescription does not exceed the FDA-labeled dosages, and (iii) the drug is prescribed consistent with the regulations of the Board of Medicine;","type":"section","prefixes":["B","13"],"prefix":"13","entire_prefix":"B13","prefix_anchor":"B13","level":2,"prior_prefix":"B12","next_prefix":"B14"},"15":{"id":293561,"text":"Require that when any carrier has previously approved prior authorization for any drug prescribed for the treatment of a mental disorder listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, no additional prior authorization shall be required by the carrier, provided that (i) the drug is a covered benefit; (ii) the prescription does not exceed the FDA-labeled dosages; (iii) the prescription has been continuously issued for no fewer than three months; and (iv) the prescriber performs an annual review of the patient to evaluate the drug’s continued efficacy, changes in the patient’s health status, and potential contraindications. Nothing in this subdivision shall prohibit a carrier from requiring prior authorization for any drug that is not listed on its prescription drug formulary at the time the initial prescription for the drug is issued;","type":"section","prefixes":["B","14"],"prefix":"14","entire_prefix":"B14","prefix_anchor":"B14","level":2,"prior_prefix":"B13","next_prefix":"B15"},"16":{"id":293562,"text":"Require a carrier to honor a prior authorization issued by the carrier for a drug regardless of whether the drug is removed from the carrier’s prescription drug formulary after the initial prescription for that drug is issued, provided that the drug and prescription are consistent with the applicable provisions of subdivision 14;","type":"section","prefixes":["B","15"],"prefix":"15","entire_prefix":"B15","prefix_anchor":"B15","level":2,"prior_prefix":"B14","next_prefix":"B16"},"17":{"id":293563,"text":"Require a carrier, beginning July 1, 2025, notwithstanding the provisions of subdivision 1 or any other provision of this section, to establish and maintain an online process that (i) links directly to all e-prescribing systems and electronic health record systems that utilize the National Council for Prescription Drug Programs SCRIPT standard and the National Council for Prescription Drug Programs Real Time Benefit Standard; (ii) can accept electronic prior authorization requests from a provider; (iii) can approve electronic prior authorization requests (a) for which no additional information is needed by the carrier to process the prior authorization request, (b) for which no clinical review is required, and (c) that meet the carrier’s criteria for approval; (iv) links directly to real-time patient out-of-pocket costs for the prescription drug, considering copayment and deductible; and (v) otherwise meets the requirements of this section. No carrier shall (a) impose a fee or charge on any person for accessing the online process as required by this subdivision or (b) access, absent provider consent, provider data via the online process other than for the enrollee. No later than July 1, 2024, a carrier shall provide contact information of any third-party vendor or other entity the carrier will use to meet the requirements of this subdivision or the requirements of § 38.2-3407.15:7 to any provider that requests such information. A carrier that posts such contact information on its website shall be considered to have met this requirement; and","type":"section","prefixes":["B","16"],"prefix":"16","entire_prefix":"B16","prefix_anchor":"B16","level":2,"prior_prefix":"B15","next_prefix":"B17"},"18":{"id":293564,"text":"Require a participating health care provider, beginning July 1, 2025, to ensure that any e-prescribing system or electronic health record system owned by or contracted for the provider to maintain an enrollee’s health record has the ability to access, at the point of prescribing, the electronic prior authorization process established by a carrier as required by subdivision 16 and the real-time patient-specific benefit information, including out-of-pocket costs and more affordable medication alternatives made available by a carrier pursuant to § 38.2-3407.15:7. A provider may request a waiver of compliance under this subdivision for undue hardship for a period specified by the appropriate regulatory authority with the Health and Human Resources Secretariat.","type":"section","prefixes":["B","17"],"prefix":"17","entire_prefix":"B17","prefix_anchor":"B17","level":2,"prior_prefix":"B16","next_prefix":"C"},"19":{"id":293565,"text":"The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B17","next_prefix":"D"},"20":{"id":293566,"text":"This section shall apply with respect to any contract between a carrier and a participating health care provider or its contracting agent that is entered into, amended, extended, or renewed on or after January 1, 2016.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"21":{"id":293567,"text":"Notwithstanding any law to the contrary, the provisions of this section shall not apply to:","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"E1"},"22":{"id":293568,"text":"Coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid), Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE);","type":"section","prefixes":["E","1"],"prefix":"1","entire_prefix":"E1","prefix_anchor":"E1","level":2,"prior_prefix":"E","next_prefix":"E2"},"23":{"id":293569,"text":"Accident only, credit or disability insurance, long-term care insurance, TRICARE supplement, Medicare supplement, or workers’ compensation coverages;","type":"section","prefixes":["E","2"],"prefix":"2","entire_prefix":"E2","prefix_anchor":"E2","level":2,"prior_prefix":"E1","next_prefix":"E3"},"24":{"id":293570,"text":"Any dental services plan or optometric services plan as defined in § 38.2-4501; or","type":"section","prefixes":["E","3"],"prefix":"3","entire_prefix":"E3","prefix_anchor":"E3","level":2,"prior_prefix":"E2","next_prefix":"E4"},"25":{"id":293571,"text":"Any health maintenance organization that (i) contracts with one multispecialty group of physicians who are employed by and are shareholders of the multispecialty group, which multispecialty group of physicians may also contract with health care providers in the community; (ii) provides and arranges for the provision of physician services by such multispecialty group physicians or by such contracted health care providers in the community; and (iii) receives and processes at least 85 percent of prescription drug prior authorization requests in a manner that is interoperable with e-prescribing systems, electronic health records, and health information exchange platforms.","type":"section","prefixes":["E","4"],"prefix":"4","entire_prefix":"E4","prefix_anchor":"E4","level":2,"prior_prefix":"E3"}},"ancestry":[{"id":12994,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214889,"object_type":"structure","relational_id":12994,"identifier":"1","token":"38.2\/34\/1","url":"\/38.2\/34\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":57593,"structure_id":12994,"section_number":"38.2-3400","catch_line":"Application of chapter","url":"\/38.2-3400\/","token":"38.2\/34\/1\/38.2-3400","metadata":false},{"id":72072,"structure_id":12994,"section_number":"38.2-3401","catch_line":"Forms of insurance authorized","url":"\/38.2-3401\/","token":"38.2\/34\/1\/38.2-3401","metadata":false},{"id":65240,"structure_id":12994,"section_number":"38.2-3402","catch_line":"Certification to accompany application","url":"\/38.2-3402\/","token":"38.2\/34\/1\/38.2-3402","metadata":false},{"id":83988,"structure_id":12994,"section_number":"38.2-3403","catch_line":"Fraudulent procurement of policy","url":"\/38.2-3403\/","token":"38.2\/34\/1\/38.2-3403","metadata":false},{"id":65279,"structure_id":12994,"section_number":"38.2-3404","catch_line":"Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies","url":"\/38.2-3404\/","token":"38.2\/34\/1\/38.2-3404","metadata":false},{"id":62539,"structure_id":12994,"section_number":"38.2-3405","catch_line":"Certain subrogation provisions and limitations upon recovery in hospital, medical, etc., policies forbidden; 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This law was first created in 2015. The record of its establishment is cataloged in chapters 515<\/a> and 516<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. It has been modified 4 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 2019, chapter 683<\/a>; in 2023, chapters 474<\/a> and 475<\/a>; in 2024, chapters 320<\/a> and 338<\/a>; in 2025, chapters 58<\/a>, 68<\/a>, and 284<\/a>.<\/p>","references":[{"id":82040,"section_number":"38.2-3407.15:8","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for health care services","order_by":null,"url":"\/38.2-3407.15_8\/"}],"refers_to":[{"id":71060,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","order_by":null,"url":"\/38.2-3407.15\/"},{"id":87317,"section_number":"38.2-3407.15:7","catch_line":"Carrier provision of certain information","order_by":null,"url":"\/38.2-3407.15_7\/"},{"id":78064,"section_number":"38.2-4501","catch_line":"Definitions","order_by":null,"url":"\/38.2-4501\/"}],"permalink":{"id":215007,"object_type":"law","relational_id":81930,"identifier":"38.2-3407.15:2","token":"38.2\/34\/1\/38.2-3407.15_2","url":"\/38.2-3407.15_2\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.15_2\/","token":"38.2\/34\/1\/38.2-3407.15_2","dublin_core":{"Title":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for drug benefits","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.15:2","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier<\/span>” has the same meaning as provided in subsection A of § 38.2-3407.15<\/a>.\n\t\t\t“Prior authorization<\/span>” means the approval process used by a carrier<\/span> before certain drug benefits may be provided.\n\t\t\t“Provider contract<\/span>” has the same meaning as provided in subsection A of § 38.2-3407.15<\/a>.\n\t\t\t“Supplementation<\/span>” means a request communicated by the carrier<\/span> to the prescriber or his designee for additional information, limited to items specifically requested on the applicable prior authorization<\/span> request, necessary to approve or deny such request. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Any provider contract<\/span> between a carrier<\/span> and a participating health care provider with prescriptive authority, or its contracting agent, shall contain specific provisions that: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Require the carrier<\/span> to, in a method of its choosing, accept telephonic, facsimile, or electronic submission of prior authorization<\/span> requests that are delivered from e-prescribing systems, electronic health record systems, and health information exchange platforms that utilize the National Council for Prescription Drug Programs’ SCRIPT standards; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Require that the carrier<\/span> communicate to the prescriber or his designee within 24 hours, including weekend hours, of submission of an urgent prior authorization<\/span> request to the carrier<\/span>, if submitted telephonically or in an alternate method directed by the carrier<\/span>, that the request is approved, denied, or requires supplementation<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Require that the carrier<\/span> communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a fully completed prior authorization<\/span> request, that the request is approved, denied, or requires supplementation<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Require that the carrier<\/span> communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a properly completed supplementation<\/span> from the prescriber or his designee, that the request is approved or denied; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Require that if a prior authorization<\/span> request is approved for prescription drugs and such prescription drugs have been scheduled, provided, or delivered to the patient consistent with the authorization, the carrier<\/span> shall not revoke, limit, condition, modify, or restrict that authorization unless (i) there is evidence<\/span> that the authorization was obtained based on fraud<\/span> or misrepresentation; (ii) final actions by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer remove the drug from the market, limit its use in a manner that affects the authorization, or communicate a patient safety issue<\/span> that would affect the authorization alone or in combination with other authorizations; (iii) a combination of drugs prescribed would cause a drug interaction; or (iv) a generic or biosimilar is added to the prescription drug formulary. Nothing in this section shall require a carrier<\/span> to cover any benefit not otherwise covered or cover a prescription drug if the enrollee is no longer covered by a health plan on the date the prescription drug was scheduled, provided, or delivered; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> Require that if the prior authorization<\/span> request is denied, the carrier<\/span> shall communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within the timeframes established by subdivision 3 or 4, as applicable, the reasons for the denial; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

7.<\/span> Require that prior authorization<\/span> approved by another carrier<\/span> be honored, upon the carrier<\/span>’s receipt from the prescriber or his designee of a record demonstrating the previous carrier<\/span>’s prior authorization<\/span> approval or any written or electronic evidence<\/span> of the previous carrier<\/span>’s coverage of such drug, at least for the initial 90 days of a member’s prescription drug benefit coverage under a new health plan, subject to the provisions of the new carrier<\/span>’s evidence<\/span> of coverage and any exception listed in subdivision 5; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

8.<\/span> Require that a tracking system be used by the carrier<\/span> for all prior authorization<\/span> requests and that the identification information be provided electronically, telephonically, or by facsimile to the prescriber or his designee, upon the carrier<\/span>’s response to the prior authorization<\/span> request; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

9.<\/span> Require that the carrier<\/span>’s prescription drug formularies, all drug benefits subject to prior authorization<\/span> by the carrier<\/span>, all of the carrier<\/span>’s prior authorization<\/span> procedures, and all prior authorization<\/span> request forms accepted by the carrier<\/span> be made available through one central location on the carrier<\/span>’s website and that such information be updated by the carrier<\/span> within seven days of approved changes; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

10.<\/span> Require a carrier<\/span> to honor a prior authorization<\/span> issued by the carrier<\/span> for a drug, other than an opioid, regardless of changes in dosages of such drug, provided such drug is prescribed consistent with U.S. Food and Drug Administration-labeled dosages; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

11.<\/span> Require a carrier<\/span> to honor a prior authorization<\/span> issued by the carrier<\/span> for a drug regardless of whether the covered person<\/span> changes plans with the same carrier<\/span> and the drug is a covered benefit with the current health plan; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

12.<\/span> Require a carrier<\/span>, when requiring a prescriber to provide supplemental information that is in the covered individual’s health record or electronic health record, to identify the specific information required; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

13.<\/span> Require that no prior authorization<\/span> be required for at least one drug prescribed for substance abuse medication-assisted treatment, provided that (i) the drug is a covered benefit, (ii) the prescription does not exceed the FDA-labeled dosages, and (iii) the drug is prescribed consistent with the regulations of the Board of Medicine; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

14.<\/span> Require that when any carrier<\/span> has previously approved prior authorization<\/span> for any drug prescribed for the treatment of a mental disorder listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, no additional prior authorization<\/span> shall be required by the carrier<\/span>, provided that (i) the drug is a covered benefit; (ii) the prescription does not exceed the FDA-labeled dosages; (iii) the prescription has been continuously issued for no fewer than three months; and (iv) the prescriber performs an annual review of the patient to evaluate the drug’s continued efficacy, changes in the patient’s health status, and potential contraindications. Nothing in this subdivision shall prohibit a carrier<\/span> from requiring prior authorization<\/span> for any drug that is not listed on its prescription drug formulary at the time the initial prescription for the drug is issued; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

15.<\/span> Require a carrier<\/span> to honor a prior authorization<\/span> issued by the carrier<\/span> for a drug regardless of whether the drug is removed from the carrier<\/span>’s prescription drug formulary after the initial prescription for that drug is issued, provided that the drug and prescription are consistent with the applicable provisions of subdivision 14; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

16.<\/span> Require a carrier<\/span>, beginning July 1, 2025, notwithstanding the provisions of subdivision 1 or any other provision of this section, to establish and maintain an online process that (i) links directly to all e-prescribing systems and electronic health record systems that utilize the National Council for Prescription Drug Programs SCRIPT standard and the National Council for Prescription Drug Programs Real Time Benefit Standard; (ii) can accept electronic prior authorization<\/span> requests from a provider; (iii) can approve electronic prior authorization<\/span> requests (a) for which no additional information is needed by the carrier<\/span> to process the prior authorization<\/span> request, (b) for which no clinical review is required, and (c) that meet the carrier<\/span>’s criteria for approval; (iv) links directly to real-time patient out-of-pocket costs for the prescription drug, considering copayment and deductible; and (v) otherwise meets the requirements of this section. No carrier<\/span> shall (a) impose a fee or charge on any person<\/span> for accessing the online process as required by this subdivision or (b) access, absent provider consent, provider data via the online process other than for the enrollee. No later than July 1, 2024, a carrier<\/span> shall provide contact information of any third-party<\/span> vendor or other entity the carrier<\/span> will use to meet the requirements of this subdivision or the requirements of § 38.2-3407.15:7<\/a> to any provider that requests such information. A carrier<\/span> that posts such contact information on its website shall be considered to have met this requirement; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

17.<\/span> Require a participating health care provider, beginning July 1, 2025, to ensure that any e-prescribing system or electronic health record system owned by or contracted for the provider to maintain an enrollee’s health record has the ability to access, at the point of prescribing, the electronic prior authorization<\/span> process established by a carrier<\/span> as required by subdivision 16 and the real-time patient-specific benefit information, including out-of-pocket costs and more affordable medication alternatives made available by a carrier<\/span> pursuant to § 38.2-3407.15:7<\/a>. A provider may request a waiver<\/span> of compliance under this subdivision for undue hardship for a period specified by the appropriate regulatory authority with the Health and Human Resources Secretariat. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The Commission<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> individual controversies arising out of this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> This section shall apply with respect to any contract between a carrier<\/span> and a participating health care provider or its contracting agent that is entered into, amended, extended, or renewed on or after January 1, 2016. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Notwithstanding any law<\/span> to the contrary, the provisions of this section shall not apply to: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare<\/span>), Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid), Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE); <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Accident only, credit or disability insurance<\/span>, long-term care insurance<\/span>, TRICARE supplement, Medicare<\/span> supplement, or workers’ compensation coverages; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Any dental services plan or optometric services plan as defined in § 38.2-4501<\/a>; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Any health maintenance organization that (i) contracts<\/span> with one multispecialty group of physicians who are employed by and are shareholders of the multispecialty group, which multispecialty group of physicians may also contract with health care providers in the community; (ii) provides and arranges for the provision of physician services by such multispecialty group physicians or by such contracted health care providers in the community; and (iii) receives and processes at least 85 percent of prescription drug prior authorization<\/span> requests in a manner that is interoperable with e-prescribing systems, electronic health records, and health information exchange platforms. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\n(EFFECTIVE JANUARY 1, 2027) CARRIER CONTRACTS; REQUIRED PROVISIONS REGARDING\nPRIOR AUTHORIZATION FOR DRUG BENEFITS (\u00a7 38.2-3407.15:2)\n\nA. As used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier” has the same meaning as provided in subsection A of\n§ 38.2-3407.15.\n\t\t\t“Prior authorization” means the approval process used by a\ncarrier before certain drug benefits may be provided.\n\t\t\t“Provider contract” has the same meaning as provided in\nsubsection A of § 38.2-3407.15.\n\t\t\t“Supplementation” means a request communicated by the carrier to\nthe prescriber or his designee for additional information, limited to items\nspecifically requested on the applicable prior authorization request, necessary\nto approve or deny such request.\n\nB. Any provider contract between a carrier and a participating health care\nprovider with prescriptive authority, or its contracting agent, shall contain\nspecific provisions that:\n\n 1. Require the carrier to, in a method of its choosing, accept telephonic,\n facsimile, or electronic submission of prior authorization requests that are\n delivered from e-prescribing systems, electronic health record systems, and\n health information exchange platforms that utilize the National Council for\n Prescription Drug Programs’ SCRIPT standards;\n\n 2. Require that the carrier communicate to the prescriber or his designee\n within 24 hours, including weekend hours, of submission of an urgent prior\n authorization request to the carrier, if submitted telephonically or in an\n alternate method directed by the carrier, that the request is approved,\n denied, or requires supplementation;\n\n 3. Require that the carrier communicate electronically, telephonically, or by\n facsimile to the prescriber or his designee, within two business days of\n submission of a fully completed prior authorization request, that the request\n is approved, denied, or requires supplementation;\n\n 4. Require that the carrier communicate electronically, telephonically, or by\n facsimile to the prescriber or his designee, within two business days of\n submission of a properly completed supplementation from the prescriber or his\n designee, that the request is approved or denied;\n\n 5. Require that if a prior authorization request is approved for prescription\n drugs and such prescription drugs have been scheduled, provided, or delivered\n to the patient consistent with the authorization, the carrier shall not\n revoke, limit, condition, modify, or restrict that authorization unless (i)\n there is evidence that the authorization was obtained based on fraud or\n misrepresentation; (ii) final actions by the U.S. Food and Drug\n Administration, other regulatory agencies, or the manufacturer remove the drug\n from the market, limit its use in a manner that affects the authorization, or\n communicate a patient safety issue that would affect the authorization alone\n or in combination with other authorizations; (iii) a combination of drugs\n prescribed would cause a drug interaction; or (iv) a generic or biosimilar is\n added to the prescription drug formulary. Nothing in this section shall\n require a carrier to cover any benefit not otherwise covered or cover a\n prescription drug if the enrollee is no longer covered by a health plan on the\n date the prescription drug was scheduled, provided, or delivered;\n\n 6. Require that if the prior authorization request is denied, the carrier\n shall communicate electronically, telephonically, or by facsimile to the\n prescriber or his designee, within the timeframes established by subdivision 3\n or 4, as applicable, the reasons for the denial;\n\n 7. Require that prior authorization approved by another carrier be honored,\n upon the carrier’s receipt from the prescriber or his designee of a\n record demonstrating the previous carrier’s prior authorization approval\n or any written or electronic evidence of the previous carrier’s coverage\n of such drug, at least for the initial 90 days of a member’s\n prescription drug benefit coverage under a new health plan, subject to the\n provisions of the new carrier’s evidence of coverage and any exception\n listed in subdivision 5;\n\n 8. Require that a tracking system be used by the carrier for all prior\n authorization requests and that the identification information be provided\n electronically, telephonically, or by facsimile to the prescriber or his\n designee, upon the carrier’s response to the prior authorization\n request;\n\n 9. Require that the carrier’s prescription drug formularies, all drug\n benefits subject to prior authorization by the carrier, all of the\n carrier’s prior authorization procedures, and all prior authorization\n request forms accepted by the carrier be made available through one central\n location on the carrier’s website and that such information be updated\n by the carrier within seven days of approved changes;\n\n 10. Require a carrier to honor a prior authorization issued by the carrier for\n a drug, other than an opioid, regardless of changes in dosages of such drug,\n provided such drug is prescribed consistent with U.S. Food and Drug\n Administration-labeled dosages;\n\n 11. Require a carrier to honor a prior authorization issued by the carrier for\n a drug regardless of whether the covered person changes plans with the same\n carrier and the drug is a covered benefit with the current health plan;\n\n 12. Require a carrier, when requiring a prescriber to provide supplemental\n information that is in the covered individual’s health record or\n electronic health record, to identify the specific information required;\n\n 13. Require that no prior authorization be required for at least one drug\n prescribed for substance abuse medication-assisted treatment, provided that\n (i) the drug is a covered benefit, (ii) the prescription does not exceed the\n FDA-labeled dosages, and (iii) the drug is prescribed consistent with the\n regulations of the Board of Medicine;\n\n 14. Require that when any carrier has previously approved prior authorization\n for any drug prescribed for the treatment of a mental disorder listed in the\n most recent edition of the Diagnostic and Statistical Manual of Mental\n Disorders published by the American Psychiatric Association, no additional\n prior authorization shall be required by the carrier, provided that (i) the\n drug is a covered benefit; (ii) the prescription does not exceed the\n FDA-labeled dosages; (iii) the prescription has been continuously issued for\n no fewer than three months; and (iv) the prescriber performs an annual review\n of the patient to evaluate the drug’s continued efficacy, changes in the\n patient’s health status, and potential contraindications. Nothing in\n this subdivision shall prohibit a carrier from requiring prior authorization\n for any drug that is not listed on its prescription drug formulary at the time\n the initial prescription for the drug is issued;\n\n 15. Require a carrier to honor a prior authorization issued by the carrier for\n a drug regardless of whether the drug is removed from the carrier’s\n prescription drug formulary after the initial prescription for that drug is\n issued, provided that the drug and prescription are consistent with the\n applicable provisions of subdivision 14;\n\n 16. Require a carrier, beginning July 1, 2025, notwithstanding the provisions\n of subdivision 1 or any other provision of this section, to establish and\n maintain an online process that (i) links directly to all e-prescribing\n systems and electronic health record systems that utilize the National Council\n for Prescription Drug Programs SCRIPT standard and the National Council for\n Prescription Drug Programs Real Time Benefit Standard; (ii) can accept\n electronic prior authorization requests from a provider; (iii) can approve\n electronic prior authorization requests (a) for which no additional\n information is needed by the carrier to process the prior authorization\n request, (b) for which no clinical review is required, and (c) that meet the\n carrier’s criteria for approval; (iv) links directly to real-time\n patient out-of-pocket costs for the prescription drug, considering copayment\n and deductible; and (v) otherwise meets the requirements of this section. No\n carrier shall (a) impose a fee or charge on any person for accessing the\n online process as required by this subdivision or (b) access, absent provider\n consent, provider data via the online process other than for the enrollee. No\n later than July 1, 2024, a carrier shall provide contact information of any\n third-party vendor or other entity the carrier will use to meet the\n requirements of this subdivision or the requirements of § 38.2-3407.15:7\n to any provider that requests such information. A carrier that posts such\n contact information on its website shall be considered to have met this\n requirement; and\n\n 17. Require a participating health care provider, beginning July 1, 2025, to\n ensure that any e-prescribing system or electronic health record system owned\n by or contracted for the provider to maintain an enrollee’s health\n record has the ability to access, at the point of prescribing, the electronic\n prior authorization process established by a carrier as required by\n subdivision 16 and the real-time patient-specific benefit information,\n including out-of-pocket costs and more affordable medication alternatives made\n available by a carrier pursuant to § 38.2-3407.15:7. A provider may\n request a waiver of compliance under this subdivision for undue hardship for a\n period specified by the appropriate regulatory authority with the Health and\n Human Resources Secretariat.\n\nC. The Commission shall have no jurisdiction to adjudicate individual\ncontroversies arising out of this section.\n\nD. This section shall apply with respect to any contract between a carrier and a\nparticipating health care provider or its contracting agent that is entered\ninto, amended, extended, or renewed on or after January 1, 2016.\n\nE. Notwithstanding any law to the contrary, the provisions of this section shall\nnot apply to:\n\n 1. Coverages issued pursuant to Title XVIII of the Social Security Act, 42\n U.S.C. § 1395 et seq. (Medicare), Title XIX of the Social Security Act,\n 42 U.S.C. § 1396 et seq. (Medicaid), Title XXI of the Social Security\n Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq.\n (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE);\n\n 2. Accident only, credit or disability insurance, long-term care insurance,\n TRICARE supplement, Medicare supplement, or workers’ compensation\n coverages;\n\n 3. Any dental services plan or optometric services plan as defined in §\n 38.2-4501; or\n\n 4. Any health maintenance organization that (i) contracts with one\n multispecialty group of physicians who are employed by and are shareholders of\n the multispecialty group, which multispecialty group of physicians may also\n contract with health care providers in the community; (ii) provides and\n arranges for the provision of physician services by such multispecialty group\n physicians or by such contracted health care providers in the community; and\n (iii) receives and processes at least 85 percent of prescription drug prior\n authorization requests in a manner that is interoperable with e-prescribing\n systems, electronic health records, and health information exchange platforms.\n\nHISTORY: 2015, cc. 515, 516; 2019, c. 683; 2021, Sp. Sess. I, cc. 66, 67; 2023,\ncc. 474, 475; 2024, cc. 320, 338; 2025, cc. 58, 68, 284.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}