Written by a parent, not a doctor. Nothing here is medical advice.

Childhood Cancer Lantern
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Virginia program

Deadlines for treatment requests and keeping your doctor

Virginia sets response deadlines for certain treatment requests and protects some care after a doctor leaves a network.

What it is

Virginia sets response deadlines for certain treatment requests and protects some care after a doctor leaves a network.

Your prescriber makes the treatment request. The response deadline depends on what is requested and whether it is urgent. A response may ask for more information instead of approving treatment.

Eligibility rules
  • These authorization rules generally apply to Virginia-regulated carriers, and the step-therapy statute expressly includes state-employee coverage. A separate Virginia drug cost-sharing rule may also require patient-assistance payments to count, subject to federal and HSA-qualified-plan limits; it is not itself a prior-authorization rule. Private self-funded and public plans need a law-specific scope check.
  • A fully insured plan may be regulated by another state. The benefits office confirms policy jurisdiction and whether the employer is private or public before applying Virginia protections.
What you get
  • A 24-hour response for urgent drug requests.
  • A response within two business days for ordinary drug requests.
  • Some continued care for 90 days, or up to 180 days for a life-threatening condition, after a doctor leaves.
  • A separate drug-cost rule may count patient-assistance payments toward your share, with federal and HSA-plan limits.
What the rules cover
  • A request to skip a required cheaper drug has a 72-hour standard response clock, or 24 hours in exigent cases, on four named clinical grounds.
  • Continuity can last 90 days, up to 180 for a life-threatening condition, or through inpatient discharge. The protection excludes a contract ended for cause.
  • On a Virginia-regulated plan, a copay card or charity payment for a medicine counts toward your deductible, except on a high-deductible plan with a health savings account before the minimum deductible is met.
If you decide to apply
  1. Ask the prescriber which request was sent and whether it was marked urgent.
  2. Ask the plan in writing when it received the request, what is missing and which deadline applies.

The plan · Official page ↗

If you decide to apply
  • The prescriber supplies the clinical information. The oncology team can identify which step-therapy exception applies.
Good to know

A timely request for more information can count as a response. It is not the same as approval.

Other details
  • A medicine request must be answered within 24 hours when urgent, otherwise within two business days. A request to skip a "try this drug first" rule is answered within 72 hours, or 24 when urgent, and the oncologist can ask for it when the cheaper drug would be unsafe, would not work, has already failed, or your child is stable on the current one.
Official sources
Ask your social worker

“Which deadline applies to our treatment request, and is anything missing? Could you help the clinic and plan resolve it without interrupting care?”

Why I’m asking: I need to understand whether a wait is within the rules and what information would resolve it.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask in writing when the request arrived and which deadline applies.

Your social worker

The clinic pharmacist or nurse files the request and answers any information request the same day.

The care team

The oncologist names which clinical ground applies if a cheaper drug is being required first.

Who decides
The plan
Ask the care team
“Was this filed as urgent? Virginia gives the plan 24 hours on an urgent drug request. Can we ask the plan in writing when it received it?”

How to apply

First step: Ask the clinic whether the request was filed as urgent, and ask the plan in writing when it was received.

  1. Ask the plan in writing when the request was received and which deadline applies.
  2. If a cheaper drug is being insisted on, ask the oncologist which of the four grounds fits.

Official application / program page ↗

Where it starts: The prescriber files. Ask the plan in writing which clock applies and when it started.

What to gather

  • The date the request was filed
  • The plan member number
  • The prescriber contact

How long: 24 hours urgent, two business days standard for a drug.

What a yes looks like

An approval number and a date, given to the pharmacy or the clinic.

What a no looks like, and the next move

A refusal. Then the outside review is the next step, and a cancer denial does not have to wait for the internal appeal.

Watch out

  • A response can be a request for more information rather than a decision; ask what is missing.
  • Continued care after a provider leaves does not apply if the plan ended the contract for cause.
  • Non-drug services get their own clocks only from January 1, 2027.

Dates that change this

2027-01-01: From January 1, 2027 the same kind of clock arrives for non-drug services: 72 hours expedited and seven calendar days standard, with one health maintenance organisation model excluded.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 11, 2026.

What it is worth

24 hours for an urgent drug request, two business days for an ordinary one, 72 hours to answer a step-therapy exception, and 90 to 180 days of continued care when a doctor leaves the network.

  • $24 — Hours for an urgent drug decision
  • $2 — Business days for an ordinary drug decision
  • $72 — Hours to answer a request to skip a cheaper drug first
  • $90 — Days a doctor leaving the network must keep treating your child
  • $180 — Days of continued care for a life-threatening condition

Legal protection: Deadlines on drug prior authorisation, including at weekends · Four named clinical grounds for skipping a required cheaper drug · At least 90 days of continued care after a provider leaves the network, up to 180 for a life-threatening condition, or through discharge for an inpatient · The continuing provider takes the old contract rate as payment in full

What it costs the family: None.

The eligibility facts, as published

Plans
carriers regulated by Virginia; the step-therapy law expressly includes the state employee plan
Drug clocks
24 hours urgent, two business days standard, weekends included; a request for more information counts as a response
Step therapy
72 hours standard, 24 hours exigent, on four named clinical grounds
Continuity
90 days, up to 180 for a life-threatening condition, or through inpatient discharge

The trap: A response is not always a decision. The law lets the plan reply by asking for more information, so ask what is still missing and get it sent the same day.

Where I read this

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