Virginia Bills

Provides that prior authorization requirements currently applicable to drug benefits are applicable to the process for a carrier's approval of surgical procedures. The measure requires contracts between an insurance carrier and a participating health care provider that require the carrier's prior authorization to include provisions that prohibit the carrier, after it has approved a prior authorization request submitted by a participating health care provider, from (i) withdrawing or retracting its approval of the request or (ii) declining or refusing to pay a claim submitted for the drug benefit or surgical procedure. The measure provides that if a health plan or provider contract states that prior authorization is not required for a specific drug benefit or surgical procedure, the carrier shall not refuse to pay a claim submitted for the drug benefit or surgical procedure. The measure addresses the standards applicable to electronic submissions of requests for prior authorization and specifies that requests may be submitted in paper if the provider meets certain criteria. Finally, the measure exempts a drug benefit from prior authorization requirements if prior authorization has been approved for the drug benefit in 90 percent or more of the requests for prior authorization submitted by the provider in the preceding 12 months or if the drug is a generic medication. These provisions apply to provider contracts entered into, amended, extended, or renewed on or after January 1, 2019.