Virginia Law

Article 4. Medicaid Prior Authorization Advisory Committee.

As used in this article:

"Board" means the Board of Medical Assistance Services.

"Committee" means the Medicaid Prior Authorization Advisory Committee established pursuant to this article.

"Department" means the Department of Medical Assistance Services.

"Director" means the Director of Medical Assistance Services.

"Drug" shall have the same meaning, unless the context otherwise dictates or the Board otherwise provides by regulation, as provided in the Drug Control Act (§ 54.1-3400 et seq.).

1993, c. 537.

The Board shall amend the state plan and promulgate regulations to establish the Medicaid Prior Authorization Advisory Committee, composed of 11 members to be appointed by the Board. Five members shall be physicians, at least three of whom shall care for a significant number of Medicaid patients; four shall be pharmacists, two of whom shall be community pharmacists; one member shall be an individual receiving mental health services; and one member shall be a Medicaid recipient. A quorum for action of the Committee shall consist of six members. The members shall serve at the pleasure of the Board, and vacancies shall be filled in the same manner as the original appointment. The Board shall consider nominations made by The Medical Society of Virginia, the Old Dominion Medical Society, the Psychiatric Society of Virginia, the Virginia Pharmaceutical Association, the National Alliance on Mental Illness of Virginia and the Virginia Mental Health Consumers Association when making appointments to the Committee.

The Committee shall elect its own officers, establish its own procedural rules, and meet as needed or as called by the Board, the Director, or any two members of the Committee. The Department shall provide appropriate staffing to the Committee.

1993, c. 537; 1996, c. 515; 2012, cc. 476, 507.

A. The Committee shall make recommendations to the Board regarding drugs or categories of drugs to be subject to prior authorization and prior authorization requirements for prescription drug coverage under the state plan, as well as any subsequent amendments to or revisions of such prior authorization requirements from time to time. The Board may accept or reject such recommendations in whole or in part, and may amend or add to such recommendations, except that the Board may not add to the recommendation of drugs and categories of drugs to be subject to prior authorization.

B. In formulating its recommendations to the Board, the Committee shall not be deemed to be formulating regulations for the purposes of the Administrative Process Act (§ 2.2-4000 et seq.). The Committee shall, however, conduct public hearings prior to making such recommendations to the Board. The Committee shall give thirty days' written notice by mail of the time and place of its hearings and meetings to any manufacturer whose product is being reviewed by the Committee and to those manufacturers who request the Committee in writing that they be informed of such hearings and meetings. Such persons shall be afforded a reasonable opportunity to be heard and present information. In addition, the Committee shall give thirty days' notice of such public hearings to the public by publishing its intention to conduct hearings and meetings in the Calendar of Events of the Virginia Register of Regulations and a newspaper of general circulation located in Richmond.

C. In acting on the recommendations of the Committee, the Board shall be required to conduct further proceedings under the Administrative Process Act.

1993, c. 537.

A. The Committee shall review prescription drug products to recommend prior authorization under the state plan in accordance with this article and regulations promulgated by the Board. Such review may be initiated by the Director, the Committee itself, or by written request of the Board. The Committee shall complete its recommendations to the Board within no more than six months from receipt of any such request.

B. Coverage under the state plan for any drug requiring prior authorization shall not be approved unless the prescriber obtains prior approval of such use in accordance with regulations promulgated by the Board and procedures established by the Department.

In formulating its recommendations to the Board, the Committee shall consider the potential impact on patient care and the potential fiscal impact of prior authorization on pharmacy, prescriber, hospitalization and outpatient costs. Any proposed regulation making a drug or category of drugs subject to prior authorization shall be accompanied by a statement of the estimated impact of such action on pharmacy, prescriber, hospitalization and outpatient costs.

C. The Committee shall not review any drug for which it has recommended or the Board has required prior authorization within the previous 12 months, unless new or previously unavailable relevant and objective information is presented.

D. Confidential proprietary information identified as such by a manufacturer or supplier in writing in advance and furnished to the Committee or the Board pursuant to this article shall not be subject to the disclosure requirements of the Virginia Freedom of Information Act (§ 2.2-3700 et seq.). The Board shall establish by regulation the means by which such confidential proprietary information shall be protected.

1993, c. 537; 2004, c. 855.

The members of the Committee and of the Board, as well as the staff of the Department, shall be immune, individually and jointly, from civil liability for any act, decision, or omission done or made in performance of their duties pursuant to this article while serving as a member of such Board, Committee, or staff provided that such act, decision, or omission is not done or made in bad faith or with malicious intent.

1993, c. 537.

The Committee shall report annually to the Joint Commission on Health Care regarding its recommendations for prior authorization of drug products.

1993, c. 537.