Act 111 Prior Authorization Reform
Act 111 (H. 766) Prior Authorization Reform Law Takes Effect on 1/1/25
Note that these changes apply to commercial health plans regulated by the State (such as BCBSVT and MVP plans sold on the exchange and the Vermont State Employees Health Plan), not Medicaid, Medicare or large group health plans.
What Act 111 does:
- Requires health plans to respond to urgent prior authorization requests within 24 hours;
- For ongoing, chronic medications, requires health plans to honor prior authorization approvals for five years without going through prior authorization again; PA for shorter-term medications must be honored for a year;
- Requires health plans to implement exemptions to “step therapy” or “fail first” policies, which require a patient to try and fail one or more medications before they can access the medication recommended and prescribed by their healthcare provider;
- Read the Vermont Department of Financial Regulation FAQ document here.
- Read a fact sheet about these important “step therapy” reforms here.
- Allows patients to access at least one readily available asthma controller medication without prior authorization;
- Allows primary care providers to order tests, imaging and procedures with no prior authorization;
- Read the Vermont Department of Financial Regulation FAQ document here.
- See available resources from the American College of Radiology to assist with clinical decision making regarding imaging in the absence of PA
- If a patient switches to a new health plan, they can continue on a stable medication or treatment for at least 90 days.
- Read the text of the law here.
- Find a summary of the law here.
- Read the Vermont Department of Financial Regulation FAQ document here
- Read the Governor's letter when he signed the bill here.
- Read the VMS press statement on the Governor signing the bill here.