RD574 - Report of the Electronic Prior Authorization Work Group – November 1, 2023

Executive Summary:

During its 2023 Session, the General Assembly re-enacted amended provisions first adopted in 2022,(*1) designed to automate the prior authorization process for prescription drugs and provide real-time, patient-specific benefit information to enrollees and contracted providers for covered prescription drugs, beginning July 1, 2025. These amendments have been codified in §§ 38.2-3407.15:2 and 38.2-3407.15:7 of the Code of Virginia (Code).

The General Assembly also extended the term of the Electronic Prior Authorization Work Group through November 1, 2025, and expanded its charge to include assessing progress towards electronic prior authorization (“ePA") for prescription drugs and provider access to patient-specific prescription benefit information in real-time, evaluating the use of ePA for certain medical services, establishing a process for a real-time link to prescription coupons at the point of prescribing and recommending any statutory changes related to this charge.

This report represents the perspective and consensus of participating stakeholders, including those of the Virginia Association of Health Plans, Medical Society of Virginia, Virginia Hospital and Healthcare Association, Virginia Pharmacists Association, and other interested stakeholders. The Bureau of Insurance of the State Corporation Commission, in coordination with the Health and Human Resources Secretariat, staffed and served as facilitator of the work group.

The key findings and recommendations of the work group are as follow:

1. The work group recommends that impacted stakeholders conduct a member readiness survey and engage in associated member outreach. While affected payers and providers are making progress towards implementing ePA and real-time prescription benefit (RTPB) information, and no specific impediments have been identified, implementation may prove more challenging for small health plans, regional healthcare systems, independent non-health system facilities, and certain practitioners.

2. While eager to have ePA for medical services, the work group does not recommend mandating it in Virginia prior to the standardization of technical requirements at the federal level for Medicare Advantage and other government payer programs. In addition, the work group recommends that any future mandates for medical ePA for the private commercial market align with those ultimately adopted at the federal level to avoid creating a fragmented system that may be costly and inefficient.

3. The work group recommends the General Assembly not address prescription coupon functionality until ePA and real-time benefit tools (RTBT) for prescription drugs have been implemented and fully integrated into electronic health records (EHR).

4. Finally, the work group considers it prudent to wait until 2024 to see if and when the Centers for Medicare and Medicaid Services (CMS) names an RTPB standard for Medicare Part D before moving forward with any legislative proposals.
(*1) Chapters 474 and 475, (HB 1471 and SB 1261, respectively) Virginia Acts of Assembly – 2023 Session