SB331: Accident and sickness insurance; step therapy for psychiatric medications.
SENATE BILL NO. 331
Be it enacted by the General Assembly of Virginia:
1. That the Code of Virginia is amended by adding a section numbered 38.2-3407.13:3 as follows:
§ 38.2-3407.13:3. Step therapy for psychiatric medications.
A. As used in this section:
"Carrier" means any (i) insurer issuing individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; (ii) corporation providing individual or group accident and sickness subscription contracts; or (iii) health maintenance organization providing a health care plan for health care services.
"Covered person" means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan.
"Health benefit plan" means a policy, contract, certificate, or agreement offered by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease, and that provides coverage for prescription drugs on an outpatient basis.
"Psychiatric medication" means any drug or medication used in the treatment of a serious mental disorder, mental disease, or mental defect, or used to treat side effects caused by these medications, or any medications used to augment or temper the effects of psychiatric medications. "Psychiatric medication" includes antipsychotics, antidepressants, sedatives, or mood stabilizers.
"Step therapy" means a protocol or program that (i) establishes the specific sequence in which prescription drugs for a specified medical condition are medically appropriate for a particular covered person and are covered by a health benefit plan or (ii) in any way conditions coverage of a prescription medication on a covered person first trying an alternative medication without success.
B. No carrier delivering or issuing for delivery a health benefit plan in the Commonwealth shall use step therapy in a manner that results in a denial of or delay in coverage under the health benefit plan for any psychiatric medication that (i) is prescribed to a covered person by a physician licensed in the Commonwealth and (ii) if the health benefit plan utilizes a closed drug formulary developed pursuant to § 38.2-3407.9:01, is on that formulary.
C. The requirements of this section shall apply to all health benefit plans delivered, issued for delivery, reissued, or extended in the Commonwealth on and after January 1, 2017, or at any time thereafter when any term of the policy, contract, or plan is changed or any premium adjustment is made.
D. This section shall not apply to short-term travel, accident-only, or limited or specified disease policies or contracts, nor to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.