{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-325.5.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-325.5.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-325.5.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-325.5.html"}],"law_id":60835,"edition_id":1,"section_id":60835,"structure_id":13276,"section_number":"32.1-325.5","catch_line":"State pharmacy benefits manager","history":"2025, cc. 701, 704.","full_text":"A\n\nAs used in this section:\n\t\t\t“Pharmacy benefits manager” means the same as that term is defined in § 38.2-3465.\n\t\t\t“Spread pricing” means the model of prescription drug pricing in which the pharmacy benefits manager charges a managed care plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the pharmacy benefits manager directly or indirectly pays the pharmacist or pharmacy for pharmacist services.\n\t\t\t“State pharmacy benefits manager” means the pharmacy benefits manager contracted by the Department pursuant to this section to administer pharmacy benefits for all Medicaid recipients in the Commonwealth.B\n\nBy July 1, 2026, the Department shall select and contract with a single third-party administrator to serve as the state pharmacy benefits manager to administer all pharmacy benefits for Medicaid recipients, including those enrolled in a managed care organization by such date with whom the Department contracts for the delivery of Medicaid services. Each managed care contract entered into or renewed by the Department for the delivery of Medicaid services by a managed care organization shall require the managed care organization to contract with and utilize the state pharmacy benefits manager for the purpose of administering all pharmacy benefits for Medicaid recipients enrolled with the managed care organization. Notwithstanding the provisions of § 38.2-3470, the state pharmacy benefits manager shall adhere to subdivision A 5 of § 38.2-3467 unless otherwise prohibited by federal law.C\n\nThe Department’s contract with the state pharmacy benefits manager shall:1\n\nEstablish the state pharmacy benefits manager’s fiduciary duty owed to the Department;2\n\nRequire the use of pass-through pricing;3\n\nRequire the state pharmacy benefits manager to use the common formulary, reimbursement methodologies, and dispensing fees negotiated by the Department;4\n\nRequire transparency in drug costs, rebates collected and paid, dispensing fees paid, administrative fees, and all other charges, fees, costs, and holdbacks; and5\n\nProhibit the use of spread pricing.","order_by":null,"text":{"0":{"id":222364,"text":"As used in this section:\n\t\t\t“Pharmacy benefits manager” means the same as that term is defined in § 38.2-3465.\n\t\t\t“Spread pricing” means the model of prescription drug pricing in which the pharmacy benefits manager charges a managed care plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the pharmacy benefits manager directly or indirectly pays the pharmacist or pharmacy for pharmacist services.\n\t\t\t“State pharmacy benefits manager” means the pharmacy benefits manager contracted by the Department pursuant to this section to administer pharmacy benefits for all Medicaid recipients in the Commonwealth.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":222365,"text":"By July 1, 2026, the Department shall select and contract with a single third-party administrator to serve as the state pharmacy benefits manager to administer all pharmacy benefits for Medicaid recipients, including those enrolled in a managed care organization by such date with whom the Department contracts for the delivery of Medicaid services. Each managed care contract entered into or renewed by the Department for the delivery of Medicaid services by a managed care organization shall require the managed care organization to contract with and utilize the state pharmacy benefits manager for the purpose of administering all pharmacy benefits for Medicaid recipients enrolled with the managed care organization. Notwithstanding the provisions of § 38.2-3470, the state pharmacy benefits manager shall adhere to subdivision A 5 of § 38.2-3467 unless otherwise prohibited by federal law.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":222366,"text":"The Department’s contract with the state pharmacy benefits manager shall:","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"C1"},"3":{"id":222367,"text":"Establish the state pharmacy benefits manager’s fiduciary duty owed to the Department;","type":"section","prefixes":["C","1"],"prefix":"1","entire_prefix":"C1","prefix_anchor":"C1","level":2,"prior_prefix":"C","next_prefix":"C2"},"4":{"id":222368,"text":"Require the use of pass-through pricing;","type":"section","prefixes":["C","2"],"prefix":"2","entire_prefix":"C2","prefix_anchor":"C2","level":2,"prior_prefix":"C1","next_prefix":"C3"},"5":{"id":222369,"text":"Require the state pharmacy benefits manager to use the common formulary, reimbursement methodologies, and dispensing fees negotiated by the Department;","type":"section","prefixes":["C","3"],"prefix":"3","entire_prefix":"C3","prefix_anchor":"C3","level":2,"prior_prefix":"C2","next_prefix":"C4"},"6":{"id":222370,"text":"Require transparency in drug costs, rebates collected and paid, dispensing fees paid, administrative fees, and all other charges, fees, costs, and holdbacks; and","type":"section","prefixes":["C","4"],"prefix":"4","entire_prefix":"C4","prefix_anchor":"C4","level":2,"prior_prefix":"C3","next_prefix":"C5"},"7":{"id":222371,"text":"Prohibit the use of spread pricing.","type":"section","prefixes":["C","5"],"prefix":"5","entire_prefix":"C5","prefix_anchor":"C5","level":2,"prior_prefix":"C4"}},"ancestry":[{"id":13276,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":13275,"metadata":{},"date_created":"2026-06-26 03:44:33","date_modified":"2026-06-26 03:44:33","permalink":{"id":201355,"object_type":"structure","relational_id":13276,"identifier":"1","token":"32.1\/10\/1","url":"\/32.1\/10\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":13275,"edition_id":1,"name":"Department of Medical Assistance Services","identifier":"10","label":"chapter","depth":2,"order_by":1,"parent_id":12727,"metadata":{},"date_created":"2026-06-26 03:44:33","date_modified":"2026-06-26 03:44:33","permalink":{"id":201353,"object_type":"structure","relational_id":13275,"identifier":"10","token":"32.1\/10","url":"\/32.1\/10\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12727,"edition_id":1,"name":"Health","identifier":"32.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":201099,"object_type":"structure","relational_id":12727,"identifier":"32.1","token":"32.1","url":"\/32.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":75748,"structure_id":13276,"section_number":"32.1-323","catch_line":"Department of Medical Assistance Services","url":"\/32.1-323\/","token":"32.1\/10\/1\/32.1-323","metadata":false},{"id":73079,"structure_id":13276,"section_number":"32.1-323.1","catch_line":"Department to submit forecast of expenditures","url":"\/32.1-323.1\/","token":"32.1\/10\/1\/32.1-323.1","metadata":false},{"id":78209,"structure_id":13276,"section_number":"32.1-323.2","catch_line":"Elimination of waiting lists for certain waivers","url":"\/32.1-323.2\/","token":"32.1\/10\/1\/32.1-323.2","metadata":false},{"id":65434,"structure_id":13276,"section_number":"32.1-323.3","catch_line":"Dependents of foreign service members; waiting lists for certain waivers","url":"\/32.1-323.3\/","token":"32.1\/10\/1\/32.1-323.3","metadata":false},{"id":74370,"structure_id":13276,"section_number":"32.1-323.4","catch_line":"Department to facilitate transition of persons between certain waiver programs","url":"\/32.1-323.4\/","token":"32.1\/10\/1\/32.1-323.4","metadata":false},{"id":56444,"structure_id":13276,"section_number":"32.1-324","catch_line":"Board of Medical Assistance Services","url":"\/32.1-324\/","token":"32.1\/10\/1\/32.1-324","metadata":false},{"id":82951,"structure_id":13276,"section_number":"32.1-324.1","catch_line":"Authority to administer oaths, conduct hearings; obtaining relevant documents and other information","url":"\/32.1-324.1\/","token":"32.1\/10\/1\/32.1-324.1","metadata":false},{"id":68172,"structure_id":13276,"section_number":"32.1-324.2","catch_line":"Director to facilitate communication","url":"\/32.1-324.2\/","token":"32.1\/10\/1\/32.1-324.2","metadata":false},{"id":75151,"structure_id":13276,"section_number":"32.1-324.3","catch_line":"Uninsured Medical Catastrophe Fund established","url":"\/32.1-324.3\/","token":"32.1\/10\/1\/32.1-324.3","metadata":false},{"id":77747,"structure_id":13276,"section_number":"32.1-325","catch_line":"Board to submit plan for medical assistance services to U.S. Secretary of Health and Human Services pursuant to federal law; 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individuals confined in state correctional facilities","url":"\/32.1-325.04\/","token":"32.1\/10\/1\/32.1-325.04","metadata":false},{"id":75066,"structure_id":13276,"section_number":"32.1-325.1","catch_line":"Appeals of agency determinations","url":"\/32.1-325.1\/","token":"32.1\/10\/1\/32.1-325.1","metadata":false},{"id":87103,"structure_id":13276,"section_number":"32.1-325.1:1","catch_line":"Definitions; recovery of overpayment for medical assistance services","url":"\/32.1-325.1_1\/","token":"32.1\/10\/1\/32.1-325.1_1","metadata":false},{"id":56047,"structure_id":13276,"section_number":"32.1-325.2","catch_line":"Department is payor of last resort","url":"\/32.1-325.2\/","token":"32.1\/10\/1\/32.1-325.2","metadata":false},{"id":60758,"structure_id":13276,"section_number":"32.1-325.3","catch_line":"Disclosure or use of information for purpose not connected with medical assistance program; Department not subject to certain disclosure","url":"\/32.1-325.3\/","token":"32.1\/10\/1\/32.1-325.3","metadata":false},{"id":55595,"structure_id":13276,"section_number":"32.1-325.4","catch_line":"Penalty for violation","url":"\/32.1-325.4\/","token":"32.1\/10\/1\/32.1-325.4","metadata":false},{"id":60835,"structure_id":13276,"section_number":"32.1-325.5","catch_line":"State pharmacy benefits manager","url":"\/32.1-325.5\/","token":"32.1\/10\/1\/32.1-325.5","metadata":false},{"id":62094,"structure_id":13276,"section_number":"32.1-326","catch_line":"Director may make payments to or for eligible persons in state-owned medical facilities","url":"\/32.1-326\/","token":"32.1\/10\/1\/32.1-326","metadata":false},{"id":75399,"structure_id":13276,"section_number":"32.1-326.1","catch_line":"Department to operate program of estate recovery","url":"\/32.1-326.1\/","token":"32.1\/10\/1\/32.1-326.1","metadata":false},{"id":86309,"structure_id":13276,"section_number":"32.1-326.2","catch_line":"Pilot school\/community health centers","url":"\/32.1-326.2\/","token":"32.1\/10\/1\/32.1-326.2","metadata":false},{"id":69227,"structure_id":13276,"section_number":"32.1-326.3","catch_line":"Special education health services; 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This law was first created in 2025. The record of its establishment is cataloged in chapters 701<\/a> and 704<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year.<\/p>","references":false,"refers_to":[{"id":60000,"section_number":"38.2-3465","catch_line":"Definitions","order_by":null,"url":"\/38.2-3465\/"},{"id":73357,"section_number":"38.2-3467","catch_line":"Prohibited conduct by carriers and pharmacy benefits managers","order_by":null,"url":"\/38.2-3467\/"},{"id":72179,"section_number":"38.2-3470","catch_line":"Scope of article","order_by":null,"url":"\/38.2-3470\/"}],"permalink":{"id":201437,"object_type":"law","relational_id":60835,"identifier":"32.1-325.5","token":"32.1\/10\/1\/32.1-325.5","url":"\/32.1-325.5\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-325.5\/","token":"32.1\/10\/1\/32.1-325.5","dublin_core":{"Title":"State pharmacy benefits manager","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-325.5","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section:\n\t\t\t“Pharmacy benefits manager<\/span>” means the same as that term is defined in § 38.2-3465<\/a>.\n\t\t\t“Spread pricing<\/span>” means the model of prescription drug pricing in which the pharmacy benefits manager<\/span> charges a managed care plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the pharmacy benefits manager<\/span> directly or indirectly pays the pharmacist or pharmacy for pharmacist services.\n\t\t\t“State pharmacy benefits manager<\/span><\/span>” means the pharmacy benefits manager<\/span> contracted by the Department<\/span> pursuant to this section to administer pharmacy benefits for all Medicaid recipients in the Commonwealth. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> By July 1, 2026, the Department<\/span> shall select and contract<\/span> with a single third-party<\/span> administrator to serve as the state pharmacy benefits manager<\/span><\/span> to administer all pharmacy benefits for Medicaid recipients, including those enrolled in a managed care organization by such date with whom the Department<\/span> contracts<\/span> for the delivery of Medicaid services. Each managed care contract<\/span> entered into or renewed by the Department<\/span> for the delivery of Medicaid services by a managed care organization shall require the managed care organization to contract<\/span> with and utilize the state pharmacy benefits manager<\/span><\/span> for the purpose of administering all pharmacy benefits for Medicaid recipients enrolled with the managed care organization. Notwithstanding the provisions of § 38.2-3470<\/a>, the state pharmacy benefits manager<\/span><\/span> shall adhere to subdivision A 5 of § 38.2-3467<\/a> unless otherwise prohibited by federal law<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The Department<\/span>’s contract<\/span> with the state pharmacy benefits manager<\/span><\/span> shall: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Establish the state pharmacy benefits manager<\/span><\/span>’s fiduciary duty owed to the Department<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Require the use of pass-through pricing; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Require the state pharmacy benefits manager<\/span><\/span> to use the common formulary, reimbursement methodologies, and dispensing fees negotiated by the Department<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Require transparency in drug costs, rebates collected and paid, dispensing fees paid, administrative fees, and all other charges, fees, costs, and holdbacks; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Prohibit the use of spread pricing<\/span>. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nSTATE PHARMACY BENEFITS MANAGER (\u00a7 32.1-325.5)\n\nA. As used in this section:\n\t\t\t“Pharmacy benefits manager” means the same as that term is\ndefined in § 38.2-3465.\n\t\t\t“Spread pricing” means the model of prescription drug pricing in\nwhich the pharmacy benefits manager charges a managed care plan a contracted\nprice for prescription drugs, and the contracted price for the prescription\ndrugs differs from the amount the pharmacy benefits manager directly or\nindirectly pays the pharmacist or pharmacy for pharmacist services.\n\t\t\t“State pharmacy benefits manager” means the pharmacy benefits\nmanager contracted by the Department pursuant to this section to administer\npharmacy benefits for all Medicaid recipients in the Commonwealth.\n\nB. By July 1, 2026, the Department shall select and contract with a single\nthird-party administrator to serve as the state pharmacy benefits manager to\nadminister all pharmacy benefits for Medicaid recipients, including those\nenrolled in a managed care organization by such date with whom the Department\ncontracts for the delivery of Medicaid services. Each managed care contract\nentered into or renewed by the Department for the delivery of Medicaid services\nby a managed care organization shall require the managed care organization to\ncontract with and utilize the state pharmacy benefits manager for the purpose of\nadministering all pharmacy benefits for Medicaid recipients enrolled with the\nmanaged care organization. Notwithstanding the provisions of § 38.2-3470,\nthe state pharmacy benefits manager shall adhere to subdivision A 5 of §\n38.2-3467 unless otherwise prohibited by federal law.\n\nC. The Department’s contract with the state pharmacy benefits manager\nshall:\n\n 1. Establish the state pharmacy benefits manager’s fiduciary duty owed\n to the Department;\n\n 2. Require the use of pass-through pricing;\n\n 3. Require the state pharmacy benefits manager to use the common formulary,\n reimbursement methodologies, and dispensing fees negotiated by the Department;\n\n 4. Require transparency in drug costs, rebates collected and paid, dispensing\n fees paid, administrative fees, and all other charges, fees, costs, and\n holdbacks; and\n\n 5. Prohibit the use of spread pricing.\n\nHISTORY: 2025, cc. 701, 704.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}