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SESSION ENROLLED VIRGINIA ACTS OF ASSEMBLY –– CHAPTER E An Act to amend and reenact § 38.2-3407.15:2 of the Code of Virginia and to amend the Code of N disclosure of certain information.red 38.2-3407.15:7, relating to health insurance;
VIRGINIA ACTS OF ASSEMBLY -- 2022 SESSION CHAPTER 284 An Act to amend and reenact § 38.2-3407.15:2 of the Code of Virginia and to amend the Code of Virginia by adding a section numbered 38.2-3407.15:7, relating to health insurance;
carrier R O [H 360] L Approved L Be it enacted by the General Assembly of Virginia:
carrier disclosure of certain information.
E 1.
[H 360] Approved April 8, 2022 Be it enacted by the General Assembly of Virginia:
That § 38.2-3407.15:2 of the Code of Virginia is amended and reenacted and that the Code of D Vir§ 38.2-3407.15:2.
1.
That § 38.2-3407.15:2 of the Code of Virginia is amended and reenacted and that the Code of Virginia is amended by adding a section numbered 38.2-3407.15:7 as follows:
§ 38.2-3407.15:2.
"Prior authorization" means the approval process used by a carrier before certain drug benefits may be provided.
be provided.thorization" means the approval process used by a carrier before certain drug benefits may "Provider contract" has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.
"Provider contract" has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.
"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 a prior authorization request.
"Supplementation" means a request communicated by the carrier to the prescriber or his desigHee, for additional information, limited to items specifically requested on the applicable prior authori3ation reqB.
B.
R 1.
1.
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 requires supplementation;lternate method directed by the carrier, that the request is approved, denied, or 3.
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 if the prior authorization request is denied, the carrier shall communicate established by subdivision 3 or 4, as applicable, the reasons for the denial;gnee, within the timeframes 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;
6.
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 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's response to the prior authorization request;
8.
Require a carrier to honor a prior authorization issued by the carrier for a drug regardless of the current health plan;on changes plans with the same carrier and the drug is a covered benefit with 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;
Require a carrier, when requiring a prescriber to provide supplemental information that is in the of 3 covered individual's health record or electronic health record, to identify the specific information required;
11.
12.
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;
of 3 12.
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 the electronic prior authorization process established by a carrier as required by subdivision 15 and the real time cost information data for a covered prescription drug made available by a carrier pursuant to § 38.2-3407.15:7.
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 the electronic prior authorization process established by a carrier as required by subdivision 15 and the real-time cost information data for a covered prescription drug made available by a carrier pursuant to § 38.2-3407.15:7.
(federal employees), or 10 U.S.C.
(federal employees), or U.S.C.
of 3 "Enrollee" has the same meaning as provided in § 38.2-3407.10.
"Enrollee" has the same meaning as provided in § 38.2-3407.10.
E "Provider" has the same meaning as provided in § 38.2-3407.10.
"Provider" has the same meaning as provided in § 38.2-3407.10.
Beginning July 1, 2025, any carrier or its pharmacy benefits manager shall provide real-time cost information data to enrollees and contracted providers for a covered prescription drug, includiRg any Such cost information data shall be available to the provider in a format that a provider can aOcess and.
Beginning July 1, 2025, any carrier or its pharmacy benefits manager shall provide real-time cost information data to enrollees and contracted providers for a covered prescription drug, including any of 3 cost-sharing requirement or prior authorization requirements, and shall ensure that the data is accurate.
understand such as through the provider's e-prescribing system or electronic health record system for which the carrier or pharmacy benefits manager or its designated subcontractor has adopted thatL utilizes the National Council for Prescription Drug Programs SCRIPT standard from which the proLider 2.
Such cost information data shall be available to the provider in a format that a provider can access and understand such as through the provider's e-prescribing system or electronic health record system for which the carrier or pharmacy benefits manager or its designated subcontractor has adopted that utilizes the National Council for Prescription Drug Programs SCRIPT standard from which the provider makes the request.
That the State Corporation Commission's Bureau of Insurance (the Bureau) shall, in E coordination with the Secretary of Health and Human Resources, establish a work group to evaluate and make recommendations to modify the process for prior authorization for drug D benefits in order to maximize efficiency and minimize delays.
2.
Such recommendations shall include a single standardized process as required by this act and any recommendations for necessary representatives from the Virginia Association of Health Plans, the Medical Society of Virginia, the National Council for Prescription Drug Programs, the Virginia Pharmacists Association, and the Virginia Hospital and Healthcare Association, and other parties with an interest in the underlying technology.
That the State Corporation Commission's Bureau of Insurance (the Bureau) shall, in coordination with the Secretary of Health and Human Resources, establish a work group to evaluate and make recommendations to modify the process for prior authorization for drug benefits in order to maximize efficiency and minimize delays.
The work group shall report its findings and recommendations to the Chairmen of theH Senate Committee on Commerce and Labor and the House Committee on Commerce and Energy 3 3.
Such recommendations shall include a single standardized process as required by this act and any recommendations for necessary statutory or regulatory changes.
That the provisions of the first enactment of this act shall not become effective unless reeEacted by the 2023 Session of the General Assembly.
The work group shall include relevant stakeholders, including representatives from the Virginia Association of Health Plans, the Medical Society of Virginia, the National Council for Prescription Drug Programs, the Virginia Pharmacists Association, and the Virginia Hospital and Healthcare Association, and other parties with an interest in the underlying technology.
The work group shall report its findings and recommendations to the Chairmen of the Senate Committee on Commerce and Labor and the House Committee on Commerce and Energy by November 1, 2022.
3.
That the provisions of the first enactment of this act shall not become effective unless reenacted by the 2023 Session of the General Assembly.
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