During its 2023 Session, the General Assembly enacted SB 1261 and HB 1471, extending the Electronic Prior Authorization (ePA) Work Group through November 1, 2025, and expanding its charge to include (i) assessing progress towards ePA for prescription drugs and provider access to patient-specific real-time prescription benefit (RTPB) information, (ii) evaluating the use of ePA for surgery and other procedures, (iii) evaluating and making recommendations for establishing a process for a real-time link to prescription coupons at the point of prescribing, and (iv) making recommendations for any additional statutory changes required to facilitate implementation or to establish such processes.

As part of its charge, the work group has sought to ensure that carriers and providers operate under a unified and consistent set of technical standards and requirements when processing ePA requests for prescription drugs and medical items and services in both the public and private health insurance marketplace. The national mandate for Medicare and Medicaid plan sponsors and payers to automate prior authorization is driving progress towards this end. Consequently, as it maps out a plan for implementing ePA in the private commercial market in Virginia, the work group is closely monitoring parallel federal developments for future alignment.

During this reporting period, several major rules have been proposed and adopted at the federal level to advance ePA. Each has been considered by the work group in making the following consensus recommendations:

1. Virginia should move forward with the implementation of ePA and RTPB processes for prescription drugs effective July 1, 2025, as required in §§ 38.2-3407.15:2 and 38.2-3407.15:7 of the Code, while impacted stakeholder groups should consider launching an informational campaign to inform and educate their members. As a corollary, the statutory undue hardship waiver in § 38.2-3407.15:2 B 17 must be available to qualifying providers.

2. Virginia should align its technical standards and requirements for medical ePA (currently encompassing medical “items and services" in relevant federal rules) for the private commercial health plans and providers with those ultimately adopted at the federal level to avoid creating a fragmented and inefficient system. While significant progress is being made at the federal level and among impacted payers and providers, more work remains to be done before Virginia should require implementation. The work group recommends the General Assembly consider extending the work group’s term to November 1, 2028, for the purpose of continuing to serve as a forum for monitoring anticipated federal developments and assessing progress over the next year towards implementation of medical ePA; assessing industry readiness; evaluating policies that support the implementation of ePA for medical items and services; and, by November 1, 2025, communicating a date certain to the General Assembly for private health plans and providers to implement medical ePA.

3. The work group recommends tabling further consideration of establishing an online process for a real-time link at the point of prescribing for any available prescription coupons until full implementation and integration of ePA and RTPB tools for prescription drugs.

4. Within a scope consistent with federal electronic prior authorization rulemaking, task the work group with evaluating and recommending policy proposals that will support the effective and efficient adoption of ePA for medical items and services.