VirginiaHB4812026 Regular SessionHouseWALLET

Prior authorization; requiring physician review for denial.

Sponsored By: Patrick A. Hope (Democratic)

Signed by Governor

Summary

Prior authorization; requiring physician review for denial. Prohibits a health insurance carrier from making an adverse determination of a prior authorization request (i) for prescription drugs unless such denial has been reviewed and approved by a licensed physician or, if a licensed physician is not available, by a licensed pharmacist or (ii) for health care services unless such adverse determination has been reviewed and approved by (a) a licensed physician; (b) in the case of mental health services, a licensed mental health provider if a licensed physician is unavailable; or (c) in the case of dental services, a licensed dentist if a licensed physician is unavailable.

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Bill Overview

Analyzed Economic Effects

10 provisions identified: 8 benefits, 1 costs, 1 mixed.

Clinical review before patients' coverage denials

Insurers cannot deny a prior approval request for prescription drugs or health care without a licensed physician reviewing and approving the denial. If no physician is available, a licensed pharmacist can review and approve a drug denial. For mental health services, a licensed mental health provider can do so when no physician is available. For dental services, a licensed dentist can do so when no physician is available.

Fewer approval barriers for addiction treatment

Virginia insurers cannot require prior approval for at least one covered drug used in medication-assisted treatment for substance-use disorder. The prescription must follow FDA-labeled dosage limits and Board of Medicine regulations. The law does not require coverage of an otherwise excluded drug. This rule covers provider contracts entered, amended, extended, or renewed on or after January 1, 2016.

Mental health patients keep drug approvals

Virginia insurers cannot require repeated approval for previously approved, covered drugs treating disorders listed in the latest Diagnostic and Statistical Manual. Prescriptions must continue for at least three months and stay within FDA-labeled dosage limits. Prescribers must review effectiveness, health changes, and reasons the drug may be unsafe each year. Qualifying approvals survive later removal from the insurer's drug list, but initial prescriptions for drugs outside that list can require approval. These rules cover provider contracts entered, amended, extended, or renewed on or after January 1, 2016.

Online drug approvals show patients' costs

Beginning July 1, 2025, Virginia insurers must offer online drug approval tools using NCPDP SCRIPT and Real Time Benefit standards. The tools show patient-specific out-of-pocket costs and lower-cost medicine options when available. Requests meeting the insurer's criteria must receive automatic approval when no extra information or clinical review is needed. Participating providers must connect their owned or contracted prescribing or health-record systems; regulators can grant time-limited undue-hardship waivers. Insurers cannot charge providers for tool access or access provider data without consent, except for access to an enrollee's data. By July 1, 2024, insurers must provide requested vendor contact details or post them online.

Patients keep drug approvals through changes

A new Virginia insurer must honor a previous drug approval for at least the first 90 days of drug coverage. The prescriber must provide proof of the earlier approval or coverage; the new plan's coverage terms and continued-approval exceptions still apply. When patients switch plans within the same insurer, approvals remain valid if the new plan covers the drug. Insurers must also keep non-opioid drug approvals when doses change within FDA-labeled limits. These rules cover provider contracts entered, amended, extended, or renewed on or after January 1, 2016.

Patients' approved care gains stronger protections

Virginia insurers generally cannot change or limit approved care once it is scheduled or provided as authorized. Drug protection also applies after delivery, with exceptions for fraud, misrepresentation, specified regulatory or manufacturer actions, harmful interactions, or newly listed generics or biosimilars. Beginning January 1, 2027, service-approval exceptions include provider-requested changes, fraud, misrepresentation, and qualifying final federal agency or manufacturer actions affecting the service or safety. Approval protections do not add benefits excluded by the plan. Insurers need not cover drugs or services after the patient's plan coverage ends.

Public approval rules protect patients' claims

The earlier Virginia drug rules require one website location for covered-drug lists, approval requirements, procedures, and forms, updated within seven days of approved changes. Beginning January 1, 2027, insurers must publicly post services, codes, procedures, forms, and each requirement's effective date, updating them by that date. Providers must receive at least 30 calendar days' notice of changes; older requirements can carry a January 1, 2027 date. Insurers cannot deny claims for missing approval when the applicable requirement was not properly posted for the service date. During pandemics, natural disasters, or other emergencies, insurers may remove approval requirements without the usual notice, but removal is not required.

New deadlines for patients' coverage decisions

Before January 1, 2027, urgent Virginia drug requests require a response within 24 hours, including weekends, using phone or another insurer-directed method. Complete requests and completed answers to requests for more information require responses within two business days. These drug rules cover provider contracts entered, amended, extended, or renewed on or after January 1, 2016. Beginning January 1, 2027, the expanded framework allows longer response windows: 72 hours, including weekends, for expedited requests and seven calendar days for standard requests. Insurers must explain denials by phone or electronically, identify missing information, and decide within the applicable deadline after receiving complete answers.

Clearer drug requests for patients' prescribers

Virginia insurers must accept drug approval requests by phone, fax, or electronic submission. Electronic routes include prescribing systems, electronic health records, and health information exchanges using NCPDP SCRIPT standards. Insurers must track every request and give prescribers identifying information with responses. When requesting information already in a patient's health record, insurers must name the specific information needed. These rules cover provider contracts entered, amended, extended, or renewed on or after January 1, 2016.

Some health plans exclude patient protections

The health care prior approval section does not cover certain health maintenance organizations using a multispecialty physician group. The group's doctors must be both employees and shareholders. The plan must arrange physician care through those doctors or contracted community providers. Patients in qualifying plans do not receive that section's protections.

Sponsors & Cosponsors

Sponsor

  • Patrick A. Hope

    Democratic • House

Cosponsors

There are no cosponsors for this bill.

Roll Call Votes

All Roll Calls

Yes: 317 • No: 1

House vote • 3/10/2026

Senate substitute agreed to by House

Yes: 98 • No: 1

Senate vote • 3/5/2026

Commerce and Labor Substitute agreed to

Yes: 0 • No: 0

Senate vote • 3/5/2026

Passed Senate with substitute Block Vote

Yes: 39 • No: 0

Senate vote • 3/4/2026

Constitutional reading dispensed Block Vote (on 2nd reading)

Yes: 39 • No: 0

Senate vote • 3/4/2026

Passed by for the day Block Vote (Voice Vote)

Yes: 0 • No: 0

Senate vote • 3/2/2026

Reported from Commerce and Labor with substitute

Yes: 13 • No: 0

House vote • 2/4/2026

Read third time and passed House

Yes: 97 • No: 0

House vote • 1/29/2026

Reported from Labor and Commerce with substitute

Yes: 22 • No: 0

House vote • 1/27/2026

Subcommittee recommends reporting with substitute

Yes: 9 • No: 0

Actions Timeline

  1. Fiscal Impact Statement from State Corporation Commission (HB481)

    4/13/2026House
  2. Acts of Assembly Chapter text (CHAP0925)

    4/13/2026Governor
  3. Approved by Governor-Chapter 925 (effective 7/1/2026)

    4/13/2026Governor
  4. Governor's Action Deadline 11:59 p.m., April 13, 2026

    3/31/2026Governor
  5. Enrolled Bill communicated to Governor on March 31, 2026

    3/31/2026House
  6. Signed by Speaker

    3/31/2026House
  7. Bill text as passed House and Senate (HB481ER)

    3/30/2026House
  8. Enrolled

    3/30/2026House
  9. Signed by President

    3/30/2026Senate
  10. Senate substitute agreed to by House (98-Y 1-N 0-A)

    3/10/2026House
  11. Passed by for the day

    3/9/2026House
  12. Fiscal Impact Statement from State Corporation Commission (HB481)

    3/5/2026House
  13. Passed Senate with substitute Block Vote (39-Y 0-N 0-A)

    3/5/2026Senate
  14. Commerce and Labor Substitute agreed to

    3/5/2026Senate
  15. Engrossed by Senate - committee substitute

    3/5/2026Senate
  16. Read third time

    3/5/2026Senate
  17. Passed by for the day Block Vote (Voice Vote)

    3/4/2026Senate
  18. Constitutional reading dispensed Block Vote (on 2nd reading) (39-Y 0-N 0-A)

    3/4/2026Senate
  19. Rules suspended

    3/4/2026Senate
  20. Committee substitute printed 26108765D-S1

    3/3/2026Senate
  21. Senate committee offered

    3/2/2026Senate
  22. Reported from Commerce and Labor with substitute (13-Y 0-N)

    3/2/2026Senate
  23. Referred to Committee on Commerce and Labor

    2/5/2026Senate
  24. Constitutional reading dispensed (on 1st reading)

    2/5/2026Senate
  25. Read third time and passed House (97-Y 0-N 0-A)

    2/4/2026House

Bill Text

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