{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.15_3.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.15_3.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.15_3.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.15_3.html"}],"law_id":77493,"edition_id":1,"section_id":77493,"structure_id":12994,"section_number":"38.2-3407.15:3","catch_line":"Carrier and intermediary contracts with pharmacy providers; disclosure and updating of maximum allowable cost of drugs; limit on termination or nonrenewal","history":"2015, c. 518.","full_text":"A\n\nAs used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.\n\t\t\t“Maximum allowable cost” means the maximum dollar amount that a carrier or its intermediary will reimburse a pharmacy provider for a group of drugs rated as “A”, “AB”, “NR”, or “NA” in the most recent edition of the Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, published by the U.S. Food and Drug Administration, or similarly rated by a nationally recognized reference.\n\t\t\t“Provider contract” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.B\n\nAny contract between a carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost, and any provider contract between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost, shall contain specific provisions that require the intermediary or carrier to:1\n\nUpdate, not less frequently than once every seven days, the maximum allowable cost list, unless there has been no change to the maximum allowable cost of any drug on the list since the last update;2\n\nVerify, not less frequently than once every seven days, that the drugs on the maximum allowable cost list are available to participating pharmacy providers from at least one regional or national pharmacy wholesaler and that the amount for each drug is not obsolete and promptly revise the maximum allowable cost if necessary to comply with this subsection;3\n\nProvide a process for each participating pharmacy provider to readily access the maximum allowable cost list specific to that provider; and4\n\nProhibit the intermediary or carrier from terminating or failing to renew its contractual relationship with a participating pharmacy provider for invoking its rights under any contractual provision required by this section.C\n\nAny contract between a carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost, and any provider contract between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost, shall contain specific provisions that require the intermediary or carrier to provide a process for an appeal, investigation, and resolution of disputes regarding maximum allowable cost drug pricing that includes:1\n\nA time period of 14 days from the date of initial claim adjudication for the participating pharmacy provider to file its dispute request;2\n\nA requirement that the dispute request be investigated and resolved within 14 days of its initiation by the participating pharmacy provider;3\n\nA telephone number at which the participating pharmacy provider may contact the carrier or its intermediary to speak to a person responsible for processing dispute requests;4\n\nA requirement that a carrier or its intermediary, if a dispute request is denied, provide (i) a reason for the denial, and (ii) the national drug code of the drug under dispute that the carrier or its intermediary contends may be purchased by the participating pharmacy provider for an amount that is equal to or less than the maximum allowable cost; and5\n\nA requirement that a carrier or its intermediary, if a dispute is successful, update the maximum allowable cost for the drug under dispute within five days of the determination of the dispute.D\n\nThe Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.E\n\nThis section shall apply with respect to contracts described in subsections B and C entered into, amended, extended, or renewed on or after January 1, 2016.","order_by":null,"text":{"0":{"id":277978,"text":"As used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.\n\t\t\t“Maximum allowable cost” means the maximum dollar amount that a carrier or its intermediary will reimburse a pharmacy provider for a group of drugs rated as “A”, “AB”, “NR”, or “NA” in the most recent edition of the Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, published by the U.S. Food and Drug Administration, or similarly rated by a nationally recognized reference.\n\t\t\t“Provider contract” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":277979,"text":"Any contract between a carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost, and any provider contract between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost, shall contain specific provisions that require the intermediary or carrier to:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":277980,"text":"Update, not less frequently than once every seven days, the maximum allowable cost list, unless there has been no change to the maximum allowable cost of any drug on the list since the last update;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":277981,"text":"Verify, not less frequently than once every seven days, that the drugs on the maximum allowable cost list are available to participating pharmacy providers from at least one regional or national pharmacy wholesaler and that the amount for each drug is not obsolete and promptly revise the maximum allowable cost if necessary to comply with this subsection;","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":277982,"text":"Provide a process for each participating pharmacy provider to readily access the maximum allowable cost list specific to that provider; and","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"5":{"id":277983,"text":"Prohibit the intermediary or carrier from terminating or failing to renew its contractual relationship with a participating pharmacy provider for invoking its rights under any contractual provision required by this section.","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"C"},"6":{"id":277984,"text":"Any contract between a carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost, and any provider contract between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost, shall contain specific provisions that require the intermediary or carrier to provide a process for an appeal, investigation, and resolution of disputes regarding maximum allowable cost drug pricing that includes:","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B4","next_prefix":"C1"},"7":{"id":277985,"text":"A time period of 14 days from the date of initial claim adjudication for the participating pharmacy provider to file its dispute request;","type":"section","prefixes":["C","1"],"prefix":"1","entire_prefix":"C1","prefix_anchor":"C1","level":2,"prior_prefix":"C","next_prefix":"C2"},"8":{"id":277986,"text":"A requirement that the dispute request be investigated and resolved within 14 days of its initiation by the participating pharmacy provider;","type":"section","prefixes":["C","2"],"prefix":"2","entire_prefix":"C2","prefix_anchor":"C2","level":2,"prior_prefix":"C1","next_prefix":"C3"},"9":{"id":277987,"text":"A telephone number at which the participating pharmacy provider may contact the carrier or its intermediary to speak to a person responsible for processing dispute requests;","type":"section","prefixes":["C","3"],"prefix":"3","entire_prefix":"C3","prefix_anchor":"C3","level":2,"prior_prefix":"C2","next_prefix":"C4"},"10":{"id":277988,"text":"A requirement that a carrier or its intermediary, if a dispute request is denied, provide (i) a reason for the denial, and (ii) the national drug code of the drug under dispute that the carrier or its intermediary contends may be purchased by the participating pharmacy provider for an amount that is equal to or less than the maximum allowable cost; and","type":"section","prefixes":["C","4"],"prefix":"4","entire_prefix":"C4","prefix_anchor":"C4","level":2,"prior_prefix":"C3","next_prefix":"C5"},"11":{"id":277989,"text":"A requirement that a carrier or its intermediary, if a dispute is successful, update the maximum allowable cost for the drug under dispute within five days of the determination of the dispute.","type":"section","prefixes":["C","5"],"prefix":"5","entire_prefix":"C5","prefix_anchor":"C5","level":2,"prior_prefix":"C4","next_prefix":"D"},"12":{"id":277990,"text":"The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C5","next_prefix":"E"},"13":{"id":277991,"text":"This section shall apply with respect to contracts described in subsections B and C entered into, amended, extended, or renewed on or after January 1, 2016.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D"}},"ancestry":[{"id":12994,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214889,"object_type":"structure","relational_id":12994,"identifier":"1","token":"38.2\/34\/1","url":"\/38.2\/34\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":57593,"structure_id":12994,"section_number":"38.2-3400","catch_line":"Application of chapter","url":"\/38.2-3400\/","token":"38.2\/34\/1\/38.2-3400","metadata":false},{"id":72072,"structure_id":12994,"section_number":"38.2-3401","catch_line":"Forms of insurance authorized","url":"\/38.2-3401\/","token":"38.2\/34\/1\/38.2-3401","metadata":false},{"id":65240,"structure_id":12994,"section_number":"38.2-3402","catch_line":"Certification to accompany application","url":"\/38.2-3402\/","token":"38.2\/34\/1\/38.2-3402","metadata":false},{"id":83988,"structure_id":12994,"section_number":"38.2-3403","catch_line":"Fraudulent procurement of policy","url":"\/38.2-3403\/","token":"38.2\/34\/1\/38.2-3403","metadata":false},{"id":65279,"structure_id":12994,"section_number":"38.2-3404","catch_line":"Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies","url":"\/38.2-3404\/","token":"38.2\/34\/1\/38.2-3404","metadata":false},{"id":62539,"structure_id":12994,"section_number":"38.2-3405","catch_line":"Certain subrogation provisions and limitations upon recovery in hospital, medical, etc., policies forbidden; 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required provisions regarding prior authorization for drug benefits","url":"\/38.2-3407.15_2\/","token":"38.2\/34\/1\/38.2-3407.15_2","metadata":false},"next_section":{"id":73491,"structure_id":12994,"section_number":"38.2-3407.15:4","catch_line":"Limit on copayment for prescription drugs; permitted disclosures","url":"\/38.2-3407.15_4\/","token":"38.2\/34\/1\/38.2-3407.15_4","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.15:3\/","history_text":"

This law was first created in 2015. The record of its establishment is cataloged in chapter 518<\/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":71060,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","order_by":null,"url":"\/38.2-3407.15\/"}],"permalink":{"id":215011,"object_type":"law","relational_id":77493,"identifier":"38.2-3407.15:3","token":"38.2\/34\/1\/38.2-3407.15_3","url":"\/38.2-3407.15_3\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.15_3\/","token":"38.2\/34\/1\/38.2-3407.15_3","dublin_core":{"Title":"Carrier and intermediary contracts with pharmacy providers; disclosure and updating of maximum allowable cost of drugs; limit on termination or nonrenewal","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.15:3","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15<\/a>.\n\t\t\t“Maximum allowable cost<\/span>” means the maximum dollar amount that a carrier or its intermediary will reimburse a pharmacy provider for a group of drugs rated as “A”, “AB<\/span>”, “NR<\/span>”, or “NA<\/span>” in the most recent edition of the Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, published by the U.S. Food and Drug Administration, or similarly rated by a nationally recognized reference.\n\t\t\t“Provider contract<\/span>” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Any contract<\/span> between a carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost<\/span>, and any provider contract<\/span> between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost<\/span>, shall contain specific provisions that require the intermediary or carrier to: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Update, not less frequently than once every seven days, the maximum allowable cost<\/span> list, unless there has been no change to the maximum allowable cost<\/span> of any drug on the list since the last update; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Verify, not less frequently than once every seven days, that the drugs on the maximum allowable cost<\/span> list are available to participating pharmacy providers from at least one regional or national pharmacy wholesaler and that the amount for each drug is not obsolete and promptly revise the maximum allowable cost<\/span> if necessary to comply with this subsection; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Provide a process for each participating pharmacy provider to readily access the maximum allowable cost<\/span> list specific to that provider; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Prohibit the intermediary or carrier from terminating or failing to renew its contractual relationship with a participating pharmacy provider for invoking its rights under any contractual provision required by this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Any contract<\/span> between a carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost<\/span>, and any provider contract<\/span> between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost<\/span>, shall contain specific provisions that require the intermediary or carrier to provide a process for an appeal<\/span>, investigation, and resolution of disputes regarding maximum allowable cost<\/span> drug pricing that includes: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> A time period of 14 days from the date of initial claim adjudication for the participating pharmacy provider to file its dispute request; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A requirement that the dispute request be investigated and resolved within 14 days of its initiation by the participating pharmacy provider; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> A telephone number at which the participating pharmacy provider may contact the carrier or its intermediary to speak to a person<\/span> responsible for processing dispute requests; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> A requirement that a carrier or its intermediary, if a dispute request is denied, provide (i) a reason for the denial, and (ii) the national drug code of the drug under dispute that the carrier or its intermediary contends may be purchased by the participating pharmacy provider for an amount that is equal to or less than the maximum allowable cost<\/span>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> A requirement that a carrier or its intermediary, if a dispute is successful, update the maximum allowable cost<\/span> for the drug under dispute within five days of the determination of the dispute. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The Commission<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> individual controversies arising out of this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> This section shall apply with respect to contracts<\/span> described in subsections B and C entered into, amended, extended, or renewed on or after January 1, 2016. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCARRIER AND INTERMEDIARY CONTRACTS WITH PHARMACY PROVIDERS; DISCLOSURE AND\nUPDATING OF MAXIMUM ALLOWABLE COST OF DRUGS; LIMIT ON TERMINATION OR NONRENEWAL\n(\u00a7 38.2-3407.15:3)\n\nA. As used in this section, unless the context requires a different meaning:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A\nof § 38.2-3407.15.\n\t\t\t“Maximum allowable cost” means the maximum dollar amount that a\ncarrier or its intermediary will reimburse a pharmacy provider for a group of\ndrugs rated as “A”, “AB”, “NR”, or\n“NA” in the most recent edition of the Approved Drug Products with\nTherapeutic Equivalence Evaluations, also known as the Orange Book, published by\nthe U.S. Food and Drug Administration, or similarly rated by a nationally\nrecognized reference.\n\t\t\t“Provider contract” has the same meaning ascribed thereto in\nsubsection A of § 38.2-3407.15.\n\nB. Any contract between a carrier and its intermediary, pursuant to which the\nintermediary has the right or obligation to establish a maximum allowable cost,\nand any provider contract between a carrier and a participating pharmacy\nprovider or its contracting agent, pursuant to which the carrier has the right\nor obligation to establish a maximum allowable cost, shall contain specific\nprovisions that require the intermediary or carrier to:\n\n 1. Update, not less frequently than once every seven days, the maximum\n allowable cost list, unless there has been no change to the maximum allowable\n cost of any drug on the list since the last update;\n\n 2. Verify, not less frequently than once every seven days, that the drugs on\n the maximum allowable cost list are available to participating pharmacy\n providers from at least one regional or national pharmacy wholesaler and that\n the amount for each drug is not obsolete and promptly revise the maximum\n allowable cost if necessary to comply with this subsection;\n\n 3. Provide a process for each participating pharmacy provider to readily\n access the maximum allowable cost list specific to that provider; and\n\n 4. Prohibit the intermediary or carrier from terminating or failing to renew\n its contractual relationship with a participating pharmacy provider for\n invoking its rights under any contractual provision required by this section.\n\nC. Any contract between a carrier and its intermediary, pursuant to which the\nintermediary has the right or obligation to establish a maximum allowable cost,\nand any provider contract between a carrier and a participating pharmacy\nprovider or its contracting agent, pursuant to which the carrier has the right\nor obligation to establish a maximum allowable cost, shall contain specific\nprovisions that require the intermediary or carrier to provide a process for an\nappeal, investigation, and resolution of disputes regarding maximum allowable\ncost drug pricing that includes:\n\n 1. A time period of 14 days from the date of initial claim adjudication for\n the participating pharmacy provider to file its dispute request;\n\n 2. A requirement that the dispute request be investigated and resolved within\n 14 days of its initiation by the participating pharmacy provider;\n\n 3. A telephone number at which the participating pharmacy provider may contact\n the carrier or its intermediary to speak to a person responsible for\n processing dispute requests;\n\n 4. A requirement that a carrier or its intermediary, if a dispute request is\n denied, provide (i) a reason for the denial, and (ii) the national drug code\n of the drug under dispute that the carrier or its intermediary contends may be\n purchased by the participating pharmacy provider for an amount that is equal\n to or less than the maximum allowable cost; and\n\n 5. A requirement that a carrier or its intermediary, if a dispute is\n successful, update the maximum allowable cost for the drug under dispute\n within five days of the determination of the dispute.\n\nD. The Commission shall have no jurisdiction to adjudicate individual\ncontroversies arising out of this section.\n\nE. This section shall apply with respect to contracts described in subsections B\nand C entered into, amended, extended, or renewed on or after January 1, 2016.\n\nHISTORY: 2015, c. 518.","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}}