                                 CODE OF VIRGINIA

DENIAL OF BENEFITS FOR CERTAIN PRESCRIPTION DRUGS PROHIBITED (§ 38.2-3407.5)

A. Each (i) 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, (ii) corporation providing individual or
group accident and sickness subscription contracts, and (iii) 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
prescription drugs, whether on an inpatient basis, outpatient basis, or both,
shall provide in each such policy, contract, plan, certificate, and evidence of
coverage that such benefits will not be denied for any drug approved by the
United States Food and Drug Administration for use in the treatment of cancer on
the basis that the drug has not been approved by the United States Food and Drug
Administration for the treatment of the specific type of cancer for which the
drug has been prescribed, provided the drug has been recognized as safe and
effective for treatment of that specific type of cancer in any of the standard
reference compendia.

B. Each (i) 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, (ii) corporation providing individual or
group accident and sickness subscription contracts, and (iii) 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
prescription drugs, whether on an inpatient basis, outpatient basis, or both,
shall provide in each such policy, contract, plan, certificate, and evidence of
coverage that such benefits will not be denied for any drug prescribed to treat
a covered indication so long as the drug has been approved by the United States
Food and Drug Administration for at least one indication and the drug is
recognized for treatment of the covered indication in one of the standard
reference compendia or in substantially accepted peer-reviewed medical
literature.

C. For the purposes of subsections A and B:
			&#8220;Peer-reviewed medical literature&#8221; means a scientific study
published only after having been critically reviewed for scientific accuracy,
validity, and reliability by unbiased independent experts in a journal that has
been determined by the International Committee of Medical Journal Editors to
have met the Uniform Requirements for Manuscripts submitted to biomedical
journals. Peer-reviewed medical literature does not include publications or
supplements to publications that are sponsored to a significant extent by a
pharmaceutical manufacturing company or health carrier.
			&#8220;Standard reference compendia&#8221; means:

   1. American Hospital Formulary Service Drug Information;

   2. National Comprehensive Cancer Network&#8217;s Drugs &amp; Biologics
   Compendium; or

   3. Elsevier Gold Standard&#8217;s Clinical Pharmacology.

D. Coverage, as described in subsections A and B, includes medically necessary
services associated with the administration of the drug.

E. Subsections A and B shall not be construed to do any of the following:

   1. Require coverage for any drug if the United States Food and Drug
   Administration has determined its use to be contraindicated for the treatment
   of the specific type of cancer or indication for which the drug has been
   prescribed;

   2. Require coverage for experimental drugs not otherwise approved for any
   indication by the United States Food and Drug Administration;

   3. Alter any law with regard to provisions limiting the coverage of drugs that
   have not been approved by the United States Food and Drug Administration;

   4. Create, impair, alter, limit, modify, enlarge, abrogate, or prohibit
   reimbursement for drugs used in the treatment of any other disease or
   condition; or

   5. Require coverage for prescription drugs in any contract, policy or plan
   that does not otherwise provide such coverage.

F. The provisions of this section shall not apply to short-term travel, or
accident-only policies, or to short-term nonrenewable policies of not more than
six months&#8217; duration.

G. The provisions of subsection A are applicable to contracts, policies or plans
delivered, issued for delivery or renewed in this Commonwealth on and after July
1, 1994, and the provisions of subsection B are applicable to contracts,
policies or plans delivered, issued for delivery or renewed in this Commonwealth
on and after July 1, 1997.

HISTORY: 1994, c. 374; 1997, c. 656; 2010, c. 443.