An Act to amend and reenact § 38.2-3407.15:2, as it shall become effective, of the Code of Virginia, relating to health insurance; carrier contracts; required provisions regarding prior authorization for prescription drugs.
HB736 amends Virginia’s health insurance code to require certain provisions in provider contracts between carriers and participating health care providers with prescriptive authority regarding prior authorization for prescription drugs. The bill standardizes how prior authorization requests must be submitted and processed, including acceptance of telephonic, fax, and electronic submissions from e-prescribing systems, electronic health records, and health information exchange platforms using NCPDP SCRIPT standards.
The bill also imposes response deadlines on carriers. For urgent requests, carriers must respond within 24 hours, including weekends, and for fully completed requests or supplementation responses, carriers must respond within two business days. If a request is denied, the carrier must provide the reasons for denial within the same applicable timeframe. In addition, the bill requires carriers to honor prior authorizations approved by a previous carrier for at least the first 90 days of coverage under a new health plan, subject to certain exceptions.
The bill amends § 38.2-3407.15:2 of the Code of Virginia, effective January 1, 2027, and changes the required terms of provider contracts for prescription drug benefits. It limits when a carrier may revoke, restrict, or modify an approved prior authorization, generally requiring the authorization to remain valid for at least six months for initial approvals and 12 months for renewals unless specified exceptions apply, such as fraud, FDA or manufacturer action, safety concerns, drug interactions, or the addition of a generic or biosimilar. The bill affects health insurers, pharmacy benefit administration practices, prescribers, and patients by creating more uniform prior authorization procedures and continuity protections when members change health plans.
The available record does not include committee transcripts or recorded votes, so there is no direct evidence of debate or opposition in the provided materials. Based on the enacted chapter text, the bill appears to reflect a policy preference for faster prior authorization decisions, greater predictability for prescribers and patients, and reduced disruption in prescription drug access when coverage changes. The absence of recorded dissent in the supplied context suggests the measure moved without documented controversy in the materials provided.
The main policy tensions inherent in the bill are between improving patient access and continuity of care on one hand, and preserving carrier flexibility to manage utilization, safety, and formulary changes on the other. The bill’s restrictions on revoking or modifying approvals, along with mandatory response deadlines and cross-carrier honoring of prior authorizations, may be viewed by insurers as limiting administrative discretion, while providers and patients are likely to support the reduced administrative burden and fewer delays. The exceptions for fraud, safety issues, FDA action, drug interactions, and generic or biosimilar substitutions are the bill’s primary safeguards for carrier concerns.