                                 CODE OF VIRGINIA

(EFFECTIVE JANUARY 1, 2027) CARRIER CONTRACTS; REQUIRED PROVISIONS REGARDING
PRIOR AUTHORIZATION FOR DRUG BENEFITS (§ 38.2-3407.15:2)

A. As used in this section, unless the context requires a different meaning:
			&#8220;Carrier&#8221; has the same meaning as provided in subsection A of
&#xA7; 38.2-3407.15.
			&#8220;Prior authorization&#8221; means the approval process used by a
carrier before certain drug benefits may be provided.
			&#8220;Provider contract&#8221; has the same meaning as provided in
subsection A of &#xA7; 38.2-3407.15.
			&#8220;Supplementation&#8221; 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. Any provider contract between a carrier and a participating health care
provider with prescriptive authority, or its contracting agent, shall contain
specific provisions that:

   1. 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&#8217; SCRIPT standards;

   2. 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;

   3. 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;

   4. 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;

   5. 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;

   6. 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;

   7. Require that prior authorization approved by another carrier be honored,
   upon the carrier&#8217;s receipt from the prescriber or his designee of a
   record demonstrating the previous carrier&#8217;s prior authorization approval
   or any written or electronic evidence of the previous carrier&#8217;s coverage
   of such drug, at least for the initial 90 days of a member&#8217;s
   prescription drug benefit coverage under a new health plan, subject to the
   provisions of the new carrier&#8217;s evidence of coverage and any exception
   listed in subdivision 5;

   8. 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&#8217;s response to the prior authorization
   request;

   9. Require that the carrier&#8217;s prescription drug formularies, all drug
   benefits subject to prior authorization by the carrier, all of the
   carrier&#8217;s prior authorization procedures, and all prior authorization
   request forms accepted by the carrier be made available through one central
   location on the carrier&#8217;s website and that such information be updated
   by the carrier within seven days of approved changes;

   10. 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;

   11. 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;

   12. Require a carrier, when requiring a prescriber to provide supplemental
   information that is in the covered individual&#8217;s health record or
   electronic health record, to identify the specific information required;

   13. 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;

   14. 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&#8217;s continued efficacy, changes in the
   patient&#8217;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. 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&#8217;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. 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&#8217;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 &#xA7; 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

   17. 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&#8217;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 &#xA7; 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. The Commission shall have no jurisdiction to adjudicate individual
controversies arising out of this section.

D. 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.

E. Notwithstanding any law to the contrary, the provisions of this section shall
not apply to:

   1. Coverages issued pursuant to Title XVIII of the Social Security Act, 42
   U.S.C. &#xA7; 1395 et seq. (Medicare), Title XIX of the Social Security Act,
   42 U.S.C. &#xA7; 1396 et seq. (Medicaid), Title XXI of the Social Security
   Act, 42 U.S.C. &#xA7; 1397aa et seq. (CHIP), 5 U.S.C. &#xA7; 8901 et seq.
   (federal employees), or 10 U.S.C. &#xA7; 1071 et seq. (TRICARE);

   2. Accident only, credit or disability insurance, long-term care insurance,
   TRICARE supplement, Medicare supplement, or workers&#8217; compensation
   coverages;

   3. Any dental services plan or optometric services plan as defined in &#xA7;
   38.2-4501; or

   4. 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.

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.