{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3418.18.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3418.18.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3418.18.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3418.18.html"}],"law_id":60567,"edition_id":1,"section_id":60567,"structure_id":14324,"section_number":"38.2-3418.18","catch_line":"Coverage for formula and enteral nutrition products as medicine","history":"2020, cc. 214, 215; 2023, cc. 271, 272.","full_text":"A\n\nNotwithstanding the provisions of \u00a7 38.2-3419, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services, whose policy, contract, or plan, including any certificate or evidence of coverage issued in connection with such policy, contract, or plan, includes coverage for medicines shall:1\n\nClassify medically necessary formula and enteral nutrition products as medicine; and2\n\nInclude coverage for medically necessary formula and enteral nutrition products on the same terms and subject to the same conditions imposed on other medicines covered under the policy, contract, or plan.B\n\nAs used in this section:\n\t\t\t“Inherited metabolic disorder” means an inherited enzymatic disorder caused by single gene defects involved in the metabolism of amino, organic, or fatty acids.\n\t\t\t“Medically necessary formula and enteral nutrition products” means any liquid or solid formulation of formula and enteral nutrition products for covered individuals requiring treatment for an inherited metabolic disorder and for which the covered individual’s physician has issued a written order stating that the formula or enteral nutrition product is medically necessary and has been proven effective as a treatment regimen for the covered individual and that the formula or enteral nutrition product is a critical source of nutrition as certified by the physician by diagnosis. The medically necessary formula or enteral products do not need to be the covered individual’s primary source of nutrition.C\n\nThe coverage required by this section shall:1\n\nApply to the partial or exclusive feeding of a covered individual by means of oral intake or enteral feeding by tube;2\n\nInclude coverage for any medical equipment, supplies, and services that are required to administer the covered formula or enteral nutrition products;3\n\nApply only when the formula and enteral nutrition products are (i) furnished pursuant to the prescription or order of a physician or other health care professional qualified to make such prescription or order for the management of an inherited metabolic disorder and (ii) used under medical supervision, which may include a home setting; and4\n\nNot apply to nutritional supplements taken electively.D\n\nNo insurer, corporation, or health maintenance organization shall impose upon any person receiving benefits for any formula and enteral nutrition products pursuant to this section any (i) copayment, coinsurance payment, or fee that is not equally imposed upon all individuals in the same benefit category, class, coinsurance level, or copayment level receiving benefits for medicines or (ii) reduction in allowable reimbursement for medicine.E\n\nThe provisions of this section shall apply to any policy, contract, or plan delivered, issued for delivery, or renewed in the Commonwealth on and after January 1, 2021.F\n\nThe provisions of this section shall not apply to short-term travel, accident-only, or limited or specified disease policies, contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans, or short-term nonrenewable policies of not more than six months’ duration. The provisions of this section shall not apply to policies, contracts, or plans issued in the individual market or small group markets.","order_by":null,"text":{"0":{"id":221390,"text":"Notwithstanding the provisions of \u00a7 38.2-3419, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services, whose policy, contract, or plan, including any certificate or evidence of coverage issued in connection with such policy, contract, or plan, includes coverage for medicines shall:","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"A1"},"1":{"id":221391,"text":"Classify medically necessary formula and enteral nutrition products as medicine; and","type":"section","prefixes":["A","1"],"prefix":"1","entire_prefix":"A1","prefix_anchor":"A1","level":2,"prior_prefix":"A","next_prefix":"A2"},"2":{"id":221392,"text":"Include coverage for medically necessary formula and enteral nutrition products on the same terms and subject to the same conditions imposed on other medicines covered under the policy, contract, or plan.","type":"section","prefixes":["A","2"],"prefix":"2","entire_prefix":"A2","prefix_anchor":"A2","level":2,"prior_prefix":"A1","next_prefix":"B"},"3":{"id":221393,"text":"As used in this section:\n\t\t\t“Inherited metabolic disorder” means an inherited enzymatic disorder caused by single gene defects involved in the metabolism of amino, organic, or fatty acids.\n\t\t\t“Medically necessary formula and enteral nutrition products” means any liquid or solid formulation of formula and enteral nutrition products for covered individuals requiring treatment for an inherited metabolic disorder and for which the covered individual’s physician has issued a written order stating that the formula or enteral nutrition product is medically necessary and has been proven effective as a treatment regimen for the covered individual and that the formula or enteral nutrition product is a critical source of nutrition as certified by the physician by diagnosis. The medically necessary formula or enteral products do not need to be the covered individual’s primary source of nutrition.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A2","next_prefix":"C"},"4":{"id":221394,"text":"The coverage required by this section shall:","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"C1"},"5":{"id":221395,"text":"Apply to the partial or exclusive feeding of a covered individual by means of oral intake or enteral feeding by tube;","type":"section","prefixes":["C","1"],"prefix":"1","entire_prefix":"C1","prefix_anchor":"C1","level":2,"prior_prefix":"C","next_prefix":"C2"},"6":{"id":221396,"text":"Include coverage for any medical equipment, supplies, and services that are required to administer the covered formula or enteral nutrition products;","type":"section","prefixes":["C","2"],"prefix":"2","entire_prefix":"C2","prefix_anchor":"C2","level":2,"prior_prefix":"C1","next_prefix":"C3"},"7":{"id":221397,"text":"Apply only when the formula and enteral nutrition products are (i) furnished pursuant to the prescription or order of a physician or other health care professional qualified to make such prescription or order for the management of an inherited metabolic disorder and (ii) used under medical supervision, which may include a home setting; and","type":"section","prefixes":["C","3"],"prefix":"3","entire_prefix":"C3","prefix_anchor":"C3","level":2,"prior_prefix":"C2","next_prefix":"C4"},"8":{"id":221398,"text":"Not apply to nutritional supplements taken electively.","type":"section","prefixes":["C","4"],"prefix":"4","entire_prefix":"C4","prefix_anchor":"C4","level":2,"prior_prefix":"C3","next_prefix":"D"},"9":{"id":221399,"text":"No insurer, corporation, or health maintenance organization shall impose upon any person receiving benefits for any formula and enteral nutrition products pursuant to this section any (i) copayment, coinsurance payment, or fee that is not equally imposed upon all individuals in the same benefit category, class, coinsurance level, or copayment level receiving benefits for medicines or (ii) reduction in allowable reimbursement for medicine.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C4","next_prefix":"E"},"10":{"id":221400,"text":"The provisions of this section shall apply to any policy, contract, or plan delivered, issued for delivery, or renewed in the Commonwealth on and after January 1, 2021.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"11":{"id":221401,"text":"The provisions of this section shall not apply to short-term travel, accident-only, or limited or specified disease policies, contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans, or short-term nonrenewable policies of not more than six months’ duration. The provisions of this section shall not apply to policies, contracts, or plans issued in the individual market or small group markets.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E"}},"ancestry":[{"id":14324,"edition_id":1,"name":"Mandated Benefits","identifier":"2","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:47:45","date_modified":"2026-06-26 03:47:45","permalink":{"id":215143,"object_type":"structure","relational_id":14324,"identifier":"2","token":"38.2\/34\/2","url":"\/38.2\/34\/2\/","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":87046,"structure_id":14324,"section_number":"38.2-3408","catch_line":"Policy providing for reimbursement for services that may be performed by certain practitioners other than physicians","url":"\/38.2-3408\/","token":"38.2\/34\/2\/38.2-3408","metadata":false},{"id":55621,"structure_id":14324,"section_number":"38.2-3409","catch_line":"Coverage of dependent children","url":"\/38.2-3409\/","token":"38.2\/34\/2\/38.2-3409","metadata":false},{"id":68501,"structure_id":14324,"section_number":"38.2-3410","catch_line":"Construction of policy generally; words \"physician\" and \"doctor\" to include dentist","url":"\/38.2-3410\/","token":"38.2\/34\/2\/38.2-3410","metadata":false},{"id":76551,"structure_id":14324,"section_number":"38.2-3411","catch_line":"Coverage of newborn children required","url":"\/38.2-3411\/","token":"38.2\/34\/2\/38.2-3411","metadata":false},{"id":71629,"structure_id":14324,"section_number":"38.2-3411.1","catch_line":"Coverage for child health supervision services","url":"\/38.2-3411.1\/","token":"38.2\/34\/2\/38.2-3411.1","metadata":false},{"id":70694,"structure_id":14324,"section_number":"38.2-3411.2","catch_line":"Coverage of adopted children required","url":"\/38.2-3411.2\/","token":"38.2\/34\/2\/38.2-3411.2","metadata":false},{"id":77817,"structure_id":14324,"section_number":"38.2-3411.3","catch_line":"Coverage for childhood immunizations","url":"\/38.2-3411.3\/","token":"38.2\/34\/2\/38.2-3411.3","metadata":false},{"id":86598,"structure_id":14324,"section_number":"38.2-3411.4","catch_line":"Coverage for infant hearing screening and related diagnostics","url":"\/38.2-3411.4\/","token":"38.2\/34\/2\/38.2-3411.4","metadata":false},{"id":63024,"structure_id":14324,"section_number":"38.2-3412","catch_line":"Repealed","url":"\/38.2-3412\/","token":"38.2\/34\/2\/38.2-3412","metadata":false},{"id":84153,"structure_id":14324,"section_number":"38.2-3412.1","catch_line":"Coverage for mental health and substance use disorders","url":"\/38.2-3412.1\/","token":"38.2\/34\/2\/38.2-3412.1","metadata":false},{"id":75255,"structure_id":14324,"section_number":"38.2-3412.1:01","catch_line":"Repealed","url":"\/38.2-3412.1_01\/","token":"38.2\/34\/2\/38.2-3412.1_01","metadata":false},{"id":67892,"structure_id":14324,"section_number":"38.2-3413","catch_line":"Repealed","url":"\/38.2-3413\/","token":"38.2\/34\/2\/38.2-3413","metadata":false},{"id":81885,"structure_id":14324,"section_number":"38.2-3414","catch_line":"Optional coverage for obstetrical services","url":"\/38.2-3414\/","token":"38.2\/34\/2\/38.2-3414","metadata":false},{"id":74497,"structure_id":14324,"section_number":"38.2-3414.1","catch_line":"Obstetrical benefits; coverage for postpartum services","url":"\/38.2-3414.1\/","token":"38.2\/34\/2\/38.2-3414.1","metadata":false},{"id":58957,"structure_id":14324,"section_number":"38.2-3415","catch_line":"Exclusion or reduction of benefits for certain causes prohibited","url":"\/38.2-3415\/","token":"38.2\/34\/2\/38.2-3415","metadata":false},{"id":69898,"structure_id":14324,"section_number":"38.2-3416","catch_line":"Repealed","url":"\/38.2-3416\/","token":"38.2\/34\/2\/38.2-3416","metadata":false},{"id":59007,"structure_id":14324,"section_number":"38.2-3417","catch_line":"Deductibles and coinsurance options required","url":"\/38.2-3417\/","token":"38.2\/34\/2\/38.2-3417","metadata":false},{"id":81514,"structure_id":14324,"section_number":"38.2-3418","catch_line":"Coverage for victims of rape or incest","url":"\/38.2-3418\/","token":"38.2\/34\/2\/38.2-3418","metadata":false},{"id":85746,"structure_id":14324,"section_number":"38.2-3418.1","catch_line":"Coverage for mammograms","url":"\/38.2-3418.1\/","token":"38.2\/34\/2\/38.2-3418.1","metadata":false},{"id":86304,"structure_id":14324,"section_number":"38.2-3418.10","catch_line":"Coverage for diabetes","url":"\/38.2-3418.10\/","token":"38.2\/34\/2\/38.2-3418.10","metadata":false},{"id":87414,"structure_id":14324,"section_number":"38.2-3418.11","catch_line":"Coverage for hospice care","url":"\/38.2-3418.11\/","token":"38.2\/34\/2\/38.2-3418.11","metadata":false},{"id":81464,"structure_id":14324,"section_number":"38.2-3418.12","catch_line":"Coverage for hospitalization and anesthesia for dental procedures","url":"\/38.2-3418.12\/","token":"38.2\/34\/2\/38.2-3418.12","metadata":false},{"id":82972,"structure_id":14324,"section_number":"38.2-3418.13","catch_line":"Coverage for the treatment of morbid obesity","url":"\/38.2-3418.13\/","token":"38.2\/34\/2\/38.2-3418.13","metadata":false},{"id":85731,"structure_id":14324,"section_number":"38.2-3418.14","catch_line":"Coverage for lymphedema","url":"\/38.2-3418.14\/","token":"38.2\/34\/2\/38.2-3418.14","metadata":false},{"id":71964,"structure_id":14324,"section_number":"38.2-3418.15","catch_line":"Coverage for prosthetic devices and components","url":"\/38.2-3418.15\/","token":"38.2\/34\/2\/38.2-3418.15","metadata":false},{"id":57543,"structure_id":14324,"section_number":"38.2-3418.15:1","catch_line":"Coverage for prosthetic devices and components","url":"\/38.2-3418.15_1\/","token":"38.2\/34\/2\/38.2-3418.15_1","metadata":false},{"id":61286,"structure_id":14324,"section_number":"38.2-3418.16","catch_line":"Coverage for telemedicine services","url":"\/38.2-3418.16\/","token":"38.2\/34\/2\/38.2-3418.16","metadata":false},{"id":81144,"structure_id":14324,"section_number":"38.2-3418.17","catch_line":"Coverage for autism spectrum disorder","url":"\/38.2-3418.17\/","token":"38.2\/34\/2\/38.2-3418.17","metadata":false},{"id":60567,"structure_id":14324,"section_number":"38.2-3418.18","catch_line":"Coverage for formula and enteral nutrition products as medicine","url":"\/38.2-3418.18\/","token":"38.2\/34\/2\/38.2-3418.18","metadata":false},{"id":79176,"structure_id":14324,"section_number":"38.2-3418.19","catch_line":"Coverage for organ, eye or tissue transplant","url":"\/38.2-3418.19\/","token":"38.2\/34\/2\/38.2-3418.19","metadata":false},{"id":69963,"structure_id":14324,"section_number":"38.2-3418.1:1","catch_line":"Repealed","url":"\/38.2-3418.1_1\/","token":"38.2\/34\/2\/38.2-3418.1_1","metadata":false},{"id":72277,"structure_id":14324,"section_number":"38.2-3418.1:2","catch_line":"Coverage for pap smears","url":"\/38.2-3418.1_2\/","token":"38.2\/34\/2\/38.2-3418.1_2","metadata":false},{"id":64216,"structure_id":14324,"section_number":"38.2-3418.1:3","catch_line":"Cost sharing for breast examinations","url":"\/38.2-3418.1_3\/","token":"38.2\/34\/2\/38.2-3418.1_3","metadata":false},{"id":80233,"structure_id":14324,"section_number":"38.2-3418.2","catch_line":"Coverage of procedures involving bones and joints","url":"\/38.2-3418.2\/","token":"38.2\/34\/2\/38.2-3418.2","metadata":false},{"id":73658,"structure_id":14324,"section_number":"38.2-3418.20","catch_line":"Coverage for hearing aids and related services [Not in effect]","url":"\/38.2-3418.20\/","token":"38.2\/34\/2\/38.2-3418.20","metadata":false},{"id":76455,"structure_id":14324,"section_number":"38.2-3418.21","catch_line":"Coverage for hearing aids and related services","url":"\/38.2-3418.21\/","token":"38.2\/34\/2\/38.2-3418.21","metadata":false},{"id":67690,"structure_id":14324,"section_number":"38.2-3418.22","catch_line":"Coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome","url":"\/38.2-3418.22\/","token":"38.2\/34\/2\/38.2-3418.22","metadata":false},{"id":79724,"structure_id":14324,"section_number":"38.2-3418.3","catch_line":"Coverage for hemophilia and congenital bleeding disorders","url":"\/38.2-3418.3\/","token":"38.2\/34\/2\/38.2-3418.3","metadata":false},{"id":86337,"structure_id":14324,"section_number":"38.2-3418.4","catch_line":"Coverage for reconstructive breast surgery; notice; eligibility","url":"\/38.2-3418.4\/","token":"38.2\/34\/2\/38.2-3418.4","metadata":false},{"id":87401,"structure_id":14324,"section_number":"38.2-3418.5","catch_line":"Coverage for early intervention services","url":"\/38.2-3418.5\/","token":"38.2\/34\/2\/38.2-3418.5","metadata":false},{"id":61674,"structure_id":14324,"section_number":"38.2-3418.6","catch_line":"Minimum hospital stay for mastectomy and certain lymph node dissection patients","url":"\/38.2-3418.6\/","token":"38.2\/34\/2\/38.2-3418.6","metadata":false},{"id":71759,"structure_id":14324,"section_number":"38.2-3418.7","catch_line":"Coverage for prostate cancer screening","url":"\/38.2-3418.7\/","token":"38.2\/34\/2\/38.2-3418.7","metadata":false},{"id":62197,"structure_id":14324,"section_number":"38.2-3418.7:1","catch_line":"Coverage for colorectal cancer screening","url":"\/38.2-3418.7_1\/","token":"38.2\/34\/2\/38.2-3418.7_1","metadata":false},{"id":63576,"structure_id":14324,"section_number":"38.2-3418.8","catch_line":"Coverage for clinical trials for treatment studies on cancer","url":"\/38.2-3418.8\/","token":"38.2\/34\/2\/38.2-3418.8","metadata":false},{"id":72556,"structure_id":14324,"section_number":"38.2-3418.9","catch_line":"Minimum hospital stay for hysterectomy","url":"\/38.2-3418.9\/","token":"38.2\/34\/2\/38.2-3418.9","metadata":false},{"id":66144,"structure_id":14324,"section_number":"38.2-3419","catch_line":"Additional mandated coverage made optional to group policy or contract holder","url":"\/38.2-3419\/","token":"38.2\/34\/2\/38.2-3419","metadata":false},{"id":57559,"structure_id":14324,"section_number":"38.2-3419.1","catch_line":"Report of costs and utilization of mandated benefits","url":"\/38.2-3419.1\/","token":"38.2\/34\/2\/38.2-3419.1","metadata":false}],"previous_section":{"id":81144,"structure_id":14324,"section_number":"38.2-3418.17","catch_line":"Coverage for autism spectrum disorder","url":"\/38.2-3418.17\/","token":"38.2\/34\/2\/38.2-3418.17","metadata":false},"next_section":{"id":79176,"structure_id":14324,"section_number":"38.2-3418.19","catch_line":"Coverage for organ, eye or tissue transplant","url":"\/38.2-3418.19\/","token":"38.2\/34\/2\/38.2-3418.19","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3418.18\/","history_text":"

This law was first created in 2020. The record of its establishment is cataloged in chapters 214<\/a> and 215<\/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 1 time. 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. That modification is as follows: in 2023, chapters 271<\/a> and 272<\/a>.<\/p>","references":false,"refers_to":[{"id":66144,"section_number":"38.2-3419","catch_line":"Additional mandated coverage made optional to group policy or contract holder","order_by":null,"url":"\/38.2-3419\/"}],"permalink":{"id":215257,"object_type":"law","relational_id":60567,"identifier":"38.2-3418.18","token":"38.2\/34\/2\/38.2-3418.18","url":"\/38.2-3418.18\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3418.18\/","token":"38.2\/34\/2\/38.2-3418.18","dublin_core":{"Title":"Coverage for formula and enteral nutrition products as medicine","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3418.18","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Notwithstanding the provisions of \u00a7 38.2-3419<\/a>, each insurer<\/span> proposing to issue<\/span> individual or group accident and sickness insurance policies<\/span> providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts<\/span>; and each health maintenance organization providing a health care plan for health care services, whose policy, contract<\/span>, or plan, including any certificate or evidence<\/span> of coverage issued in connection with such policy, contract<\/span>, or plan, includes coverage for medicines shall: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Classify medically necessary formula and enteral nutrition products<\/span> as medicine; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Include coverage for medically necessary formula and enteral nutrition products<\/span> on the same terms and subject to the same conditions imposed on other medicines covered under the policy, contract<\/span>, or plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> As used in this section:\n\t\t\t“Inherited metabolic disorder<\/span>” means an inherited enzymatic disorder caused by single gene defects involved in the metabolism of amino, organic, or fatty acids.\n\t\t\t“Medically necessary formula and enteral nutrition products<\/span>” means any liquid or solid formulation of formula and enteral nutrition products for covered individuals requiring treatment for an inherited metabolic disorder<\/span> and for which the covered individual’s physician has issued a written order<\/span> stating that the formula or enteral nutrition product is medically necessary and has been proven effective as a treatment regimen for the covered individual and that the formula or enteral nutrition product is a critical source of nutrition as certified by the physician by diagnosis. The medically necessary formula or enteral products do not need to be the covered individual’s primary source of nutrition. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The coverage required by this section shall: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Apply to the partial or exclusive feeding of a covered individual by means of oral intake or enteral feeding by tube; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Include coverage for any medical equipment, supplies, and services that are required to administer the covered formula or enteral nutrition products; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Apply only when the formula and enteral nutrition products are (i) furnished pursuant to the prescription or order<\/span> of a physician or other health care professional qualified to make such prescription or order<\/span> for the management of an inherited metabolic disorder<\/span> and (ii) used under medical supervision, which may include a home setting; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Not apply to nutritional supplements taken electively. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> No insurer<\/span>, corporation, or health maintenance organization shall impose upon any person<\/span> receiving benefits for any formula and enteral nutrition products pursuant to this section any (i) copayment, coinsurance payment, or fee that is not equally imposed upon all individuals in the same benefit category, class, coinsurance level, or copayment level receiving benefits for medicines or (ii) reduction in allowable reimbursement for medicine. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The provisions of this section shall apply to any policy, contract<\/span>, or plan delivered, issued for delivery, or renewed in the Commonwealth on and after January 1, 2021. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The provisions of this section shall not apply to short-term travel, accident-only, or limited or specified disease policies, contracts<\/span> designed for issuance to persons<\/span> eligible for coverage under Title XVIII of the Social Security Act, known as Medicare<\/span>, or any other similar coverage under state<\/span> or federal governmental plans, or short-term nonrenewable policies of not more than six months’ duration. The provisions of this section shall not apply to policies, contracts<\/span>, or plans issued in the individual market or small group markets. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCOVERAGE FOR FORMULA AND ENTERAL NUTRITION PRODUCTS AS MEDICINE (\u00a7\n38.2-3418.18)\n\nA. Notwithstanding the provisions of \u00a7 38.2-3419, each insurer proposing to\nissue individual or group accident and sickness insurance policies providing\nhospital, medical and surgical, or major medical coverage on an expense-incurred\nbasis; each corporation providing individual or group accident and sickness\nsubscription contracts; and each health maintenance organization providing a\nhealth care plan for health care services, whose policy, contract, or plan,\nincluding any certificate or evidence of coverage issued in connection with such\npolicy, contract, or plan, includes coverage for medicines shall:\n\n 1. Classify medically necessary formula and enteral nutrition products as\n medicine; and\n\n 2. Include coverage for medically necessary formula and enteral nutrition\n products on the same terms and subject to the same conditions imposed on other\n medicines covered under the policy, contract, or plan.\n\nB. As used in this section:\n\t\t\t“Inherited metabolic disorder” means an inherited enzymatic\ndisorder caused by single gene defects involved in the metabolism of amino,\norganic, or fatty acids.\n\t\t\t“Medically necessary formula and enteral nutrition products”\nmeans any liquid or solid formulation of formula and enteral nutrition products\nfor covered individuals requiring treatment for an inherited metabolic disorder\nand for which the covered individual’s physician has issued a written\norder stating that the formula or enteral nutrition product is medically\nnecessary and has been proven effective as a treatment regimen for the covered\nindividual and that the formula or enteral nutrition product is a critical\nsource of nutrition as certified by the physician by diagnosis. The medically\nnecessary formula or enteral products do not need to be the covered\nindividual’s primary source of nutrition.\n\nC. The coverage required by this section shall:\n\n 1. Apply to the partial or exclusive feeding of a covered individual by means\n of oral intake or enteral feeding by tube;\n\n 2. Include coverage for any medical equipment, supplies, and services that are\n required to administer the covered formula or enteral nutrition products;\n\n 3. Apply only when the formula and enteral nutrition products are (i)\n furnished pursuant to the prescription or order of a physician or other health\n care professional qualified to make such prescription or order for the\n management of an inherited metabolic disorder and (ii) used under medical\n supervision, which may include a home setting; and\n\n 4. Not apply to nutritional supplements taken electively.\n\nD. No insurer, corporation, or health maintenance organization shall impose upon\nany person receiving benefits for any formula and enteral nutrition products\npursuant to this section any (i) copayment, coinsurance payment, or fee that is\nnot equally imposed upon all individuals in the same benefit category, class,\ncoinsurance level, or copayment level receiving benefits for medicines or (ii)\nreduction in allowable reimbursement for medicine.\n\nE. The provisions of this section shall apply to any policy, contract, or plan\ndelivered, issued for delivery, or renewed in the Commonwealth on and after\nJanuary 1, 2021.\n\nF. The provisions of this section shall not apply to short-term travel,\naccident-only, or limited or specified disease policies, contracts designed for\nissuance to persons eligible for coverage under Title XVIII of the Social\nSecurity Act, known as Medicare, or any other similar coverage under state or\nfederal governmental plans, or short-term nonrenewable policies of not more than\nsix months’ duration. The provisions of this section shall not apply to\npolicies, contracts, or plans issued in the individual market or small group\nmarkets.\n\nHISTORY: 2020, cc. 214, 215; 2023, cc. 271, 272.","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}}