                                 CODE OF VIRGINIA

COVERAGE FOR FORMULA AND ENTERAL NUTRITION PRODUCTS AS MEDICINE (§
38.2-3418.18)

A. Notwithstanding the provisions of § 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. Classify medically necessary formula and enteral nutrition products as
   medicine; and

   2. 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.

B. As used in this section:
			&#8220;Inherited metabolic disorder&#8221; means an inherited enzymatic
disorder caused by single gene defects involved in the metabolism of amino,
organic, or fatty acids.
			&#8220;Medically necessary formula and enteral nutrition products&#8221;
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&#8217;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&#8217;s primary source of nutrition.

C. The coverage required by this section shall:

   1. Apply to the partial or exclusive feeding of a covered individual by means
   of oral intake or enteral feeding by tube;

   2. Include coverage for any medical equipment, supplies, and services that are
   required to administer the covered formula or enteral nutrition products;

   3. 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

   4. Not apply to nutritional supplements taken electively.

D. 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.

E. 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.

F. 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&#8217; duration. The provisions of this section shall not apply to
policies, contracts, or plans issued in the individual market or small group
markets.

HISTORY: 2020, cc. 214, 215; 2023, cc. 271, 272.