38.2-3407.9:01 - Prescription drug formularies
§ 38.2-3407.9:01. Prescription drug formularies.
A. Each (i) insurer proposing to issue individual or group accident andsickness insurance policies providing hospital, medical and surgical or majormedical coverage on an expense-incurred basis, (ii) corporation providingindividual or group accident and sickness subscription contracts, and (iii)health maintenance organization providing a health care plan for health careservices, whose policy, contract or plan, including any certificate orevidence of coverage issued in connection with such policy, contract or plan,includes coverage for prescription drugs on an outpatient basis may apply aformulary to the prescription drug benefits provided by the insurer,corporation, or health maintenance organization if the formulary isdeveloped, reviewed at least annually, and updated as necessary inconsultation with and with the approval of a pharmacy and therapeuticscommittee, a majority of whose members are actively practicing licensedpharmacists, physicians and other licensed health care providers.
B. If an insurer, corporation, or health maintenance organization maintainsone or more closed drug formularies, each insurer, corporation or healthmaintenance organization shall:
1. Make available to participating providers and pharmacists and to anynonpreferred or nonparticipating pharmacists as described in §§ 38.2-3407.7and 38.2-4312.1, the complete, current drug formulary or formularies, or anyupdates thereto, maintained by the insurer, corporation, or healthmaintenance organization, including a list of the prescription drugs on theformulary by major therapeutic category that specifies whether a particularprescription drug is preferred over other drugs;
2. Establish a process to allow an enrollee to obtain, without additionalcost-sharing beyond that provided for formulary prescription drugs in theenrollee's covered benefits, a specific, medically necessary nonformularyprescription drug if the formulary drug is determined by the insurer,corporation, or health maintenance organization, after reasonableinvestigation and consultation with the prescribing physician, to be aninappropriate therapy for the medical condition of the enrollee. The insurer,corporation or health maintenance organization shall act on such requestswithin one business day of receipt of the request; and
3. Establish a process to allow an enrollee to obtain, without additionalcost-sharing beyond that provided for formulary prescription drugs in theenrollee's covered benefits, a specific, medically necessary nonformularyprescription drug when the enrollee has been receiving the specificnonformulary prescription drug for at least six months previous to thedevelopment or revision of the formulary and the prescribing physician hasdetermined that the formulary drug is an inappropriate therapy for thespecific patient or that changing drug therapy presents a significant healthrisk to the specific patient. After reasonable investigation and consultationwith the prescribing physician, the insurer, corporation or healthmaintenance organization shall act on such requests within one business dayof receipt of the request. For purposes of this subsection, substituting thegeneric equivalent drug, which has been approved by the U.S. Food and DrugAdministration, for a branded version of such drug shall not constitute achange in drug therapy.
(1999, cc. 643, 649; 2000, c. 873.)