Chapter 284 of the 2025 Acts of Assembly extended the term of the existing Electronic Prior Authorization (ePA) Work Group(*1) from November 1, 2025, to November 1, 2028, and revised its charge to require its 2025 report to include (i) a final assessment of progress towards implementing ePA and real-time prescription benefit (RTPB) for prescription drugs pursuant to §§ 38.2-3407.15:2 and 38.2-3407.15:7 of the Code of Virginia (Code); and (ii) a recommended date by which private commercial health carriers and providers must implement medical ePA, as part of the work group’s larger mandate to monitor federal developments related to its implementation, assess industry progress and readiness to implement it, and evaluate policies supporting its effective and efficient adoption.(*2)

The national mandate for government plan sponsors and payers such as those under Medicare Advantage and Medicaid(*3) to implement medical ePA is driving progress towards the work group’s goal of ensuring that health carriers and providers ultimately operate under a unified and consistent set of technical standards and requirements across both public and private commercial markets.

Key Finding

As a follow-up to the work group’s 2024 readiness survey, each statutorily named stakeholder group conducted a brief assessment of progress towards implementing prescription drug ePA and RTPB. While it is too early to know the full extent of progress, stakeholder reports were nevertheless generally positive but mixed and supported anecdotally by limited data and feedback. On the one hand, carriers and providers were encouraged by the lack of concerns expressed by their constituents. On the other hand, pharmacists had not yet experienced expected signs that the new requirements are changing provider workflows from retrospective to prospective prior authorization determinations.

Key Recommendations

The work group recommends that the date for health carriers to implement medical ePA in the private commercial health insurance market be consistent with and linked by reference to the federal requirements for Medicare Advantage and Medicaid under the 2024 Prior Authorization Rule.(*4) That requirement date is currently January 1, 2027. It further recommends that legislation be proposed in the 2026 regular session of the Virginia General Assembly that would codify this date requirement and tie it to the applicable regulations, as was done in 2025 for metrics reporting. The work group also recommends that providers be required to ensure their electronic health record systems can access the ePA application programming interfaces (API) established by private commercial health carriers, but with a minimum one-year delayed effective date from the required implementation date for carriers.

The work group also recommends that it monitor and consider options for moving the prior authorization process for prescription drugs from a less retrospective to a more prospective(*5) process now that ePA and RTPB systems should be in place.
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(*1) The work group was originally created by Chapters 284 and 285 of the 2022 Acts of Assembly.
(*2) The work group charge uses the term “medical items and services" from the Centers for Medicare and Medicaid Services’ (CMS) 2024 Prior Authorization Rule rather than the term “health care services" used in § 38.2-3407.15:8. of the Code of Virginia (effective January 1, 2027). "Health care services" are defined as having the same meaning as provided in § 38.2-3407.15 of the Code except that as used in § 38.2-3407.15:8, "health care services" does not include drugs that are subject to the requirements of § 38.2-3407.15:2.
(*3) In addition, the requirements of the 2024 Prior Authorization Rule also extend to the Children’s Health Insurance Program managed care and fee-for-service plans, and Qualified Health Plans on the Federally Facilitated Exchanges.
(*4) CMS, “Advancing Interopeability and Improving Prior Authorization (CMS-0057-F)," 89 Fed. Reg. 8758 (February 8, 2024).
(*5) For this purpose, retrospective and prospective prior authorization has to do with the timing of the prior authorization for prescription drugs – that is, whether the review takes place and is completed by the prescriber or their staff before the prescription order is transmitted to the pharmacy (prospective) or after it is received at the pharmacy from the provider, submitted to the carrier for coverage and then returned to the provider for the authorization process to be completed (retrospective).