West VirginiaSB 8332025 Regular SessionSenateWALLET

Excluding pharmaceutical medication from prior authorization gold card process

Sponsored By: Laura Wakim Chapman (Republican)

Signed by Governor

§5-16-7f§9-5-32§33-15-4s§33-16-3dd§33-24-7s§33-25-8p§33-25A-8S

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Bill Overview

Analyzed Economic Effects

7 provisions identified: 4 benefits, 0 costs, 3 mixed.

Immediate medicine approval after hospital discharge

Prescriptions written for inpatients at discharge get immediate approval for at least three days when they otherwise need prior approval. The medicine must cost no more than $5,000 per day. The prescribing practitioner must mark the prescription as a discharge supply or notify the pharmacy. Prior approval is required after the three-day bridge; this is not ongoing authorization.

Patients keep approvals when changing plans

Approvals from the Public Employees Insurance Agency or Medicaid's Bureau for Medical Services carry over to other managed-care organizations and health insurers. Covered insurer and managed-care approvals also carry over to the other specified plans, including the Public Employees Insurance Agency. The carryover lasts three months and applies only to services provided in West Virginia. This reduces repeat approval steps when patients change covered plans.

Stronger review rights after care denials

Public agencies and covered insurers must use national best-practice guidelines when reviewing prior approval requests. After a denial, the practitioner can request a reviewer with a similar specialty, education, and background. Peer-to-peer consultation must finish within five business days of the request; appeals must finish within 10 business days of submission. The medical director makes the final decision, and the practitioner can consult with the director after the peer consultation. Insurers can send requests to peer review within two business days for an audit or incomplete step-therapy information.

State oversight enforces patient approval rules

Covered insurers and agencies must report to the Insurance Commissioner and Inspector General at least quarterly, or more often when needed. Reports cover request totals, denials, appeals, approvals after appeal, gold-card physicians, and reasons exemptions were revoked. The Insurance Commissioner can impose civil penalties for violations of covered insurance approval rules. The Inspector General can impose civil penalties for violations of the Bureau for Medical Services rules.

Faster decisions but strict correction deadlines

Covered public agencies and insurers must decide complete electronic prior approval requests within five business days. The deadline is two business days when delay seriously threatens life, health, or safety because of the patient's psychological state. It also applies when a practitioner familiar with the patient believes delay would cause adverse health effects. For incomplete requests, plans must identify missing information and return the request within two business days. Practitioners have three business days to respond; plans then have two business days to decide. Missing the correction deadline means denial and requires a new request.

Online approval tools for insured patients

West Virginia standardizes prior approval across public and private health plans, including public employee coverage and Medicaid. The rules cover policies delivered, issued, amended, adjusted, or renewed on or after January 1, 2024. Plans must use online portals, ready by July 1, 2024, with instructions, receipt confirmation, status updates, and links on insurance cards. Portals must list procedures, drugs, devices, medical equipment, and treatments needing approval, using nationally recognized science-based standards updated at least quarterly. They must clearly show step-therapy requirements—trying another treatment first—and past unsuccessful attempts. Only one approval is allowed per episode: care initially requested for a specific condition at one care site; out-of-network care is excluded. Electronic prescribing messages must use NCPDP SCRIPT Version 201310 or the latest backward-compatible standard.

Provider approval exemptions leave medicines out

Practitioners qualify for a gold-card approval exemption by averaging at least 30 procedures yearly with 90% final approvals during six months. The exemption lasts at least six months and can be renewed for similar periods after review. Medicines, experimental treatments, noncovered benefits, and out-of-network care remain outside the exemption, so plans can still require prior approval. The health maintenance organization exemption also excludes Medicaid services with benefit maximums or minimums set by law or agency policy. Audits can end exemptions for benefit-plan noncompliance, substantial changes from past use, or other unusual patterns; practitioners must receive written reasons.

Sponsors & Cosponsors

Sponsor

Laura Wakim Chapman
Republican • Senate

Cosponsors

There are no cosponsors for this bill.

Roll Call Votes

All Roll Calls

Yes: 263 • No: 0

House vote • 4/11/2025

Effective from passage (Roll No. 528)

Yes: 99 • No: 0

House vote • 4/11/2025

Passed House (Roll No. 523)

Yes: 98 • No: 0

Senate vote • 3/29/2025

Effective from passage (Roll No. 236)

Yes: 33 • No: 0