{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.15_4.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.15_4.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.15_4.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.15_4.html"}],"law_id":73491,"edition_id":1,"section_id":73491,"structure_id":12994,"section_number":"38.2-3407.15:4","catch_line":"Limit on copayment for prescription drugs; permitted disclosures","history":"2018, cc. 245, 602.","full_text":"A\n\nAs used in this section:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.\n\t\t\t“Copayment” means an amount an enrollee is required to pay at the point of sale in order to receive a covered prescription drug.\n\t\t\t“Enrollee” means a policyholder, subscriber, participant, or other individual covered by a health benefit plan.\n\t\t\t“Health plan” means any health benefit plan, as defined in § 38.2-3438, that provides coverage for prescription drugs.\n\t\t\t“Pharmacy benefits management” means the administration or management of prescription drug benefits provided by a carrier for the benefit of enrollees.\n\t\t\t“Pharmacy benefits manager” means an entity that performs pharmacy benefits management. The term includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a carrier.\n\t\t\t“Provider contract” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.B\n\nNo provider contract between a health carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision (i) authorizing the carrier or its pharmacy benefits manager to charge, (ii) requiring the pharmacy or pharmacist to collect, or (iii) requiring an enrollee to make, a copayment for a covered prescription drug in an amount that exceeds the least of:1\n\nThe applicable copayment for the prescription drug that would be payable in the absence of this section; or2\n\nThe cash price the enrollee would pay for the prescription drug if the enrollee purchased the prescription drug without using the enrollee’s health plan.C\n\nProvider contracts between a health carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain specific provisions that allow a pharmacy to:1\n\nDisclose to an enrollee information relating to (i) the provisions of this section and (ii) the availability of a more affordable therapeutically equivalent prescription drug;2\n\nSell a more affordable therapeutically equivalent prescription drug to an enrollee if one is available in accordance with § 54.1-3408.03; and3\n\nOffer and provide direct and limited delivery services to an enrollee as an ancillary service of the pharmacy in accordance with § 54.1-3420.2.D\n\nA pharmacy shall not be penalized by a pharmacy benefits manager or a carrier for discussing information or for selling a more affordable alternative as described in subsection C.E\n\nProvider contracts between a health carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain specific provisions that prohibit the carrier or the pharmacy benefit manager from charging a fee to a pharmacy or otherwise holding a pharmacy responsible for a fee relating to the adjudication of a claim unless the fee is reported on the remittance advice of the adjudicated claim or is set out in contract between the pharmacy benefits manager and the pharmacy or its contracting agent.F\n\nThis section shall not apply with respect to claims under an employee benefit plan under the Employee Retirement Income Security Act of 1974, Medicaid, or Medicare Part D.G\n\nThis section shall apply with respect to provider contracts entered into, amended, extended, or renewed on or after January 1, 2019.H\n\nPursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this section.I\n\nThe Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.","order_by":null,"text":{"0":{"id":264446,"text":"As used in this section:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.\n\t\t\t“Copayment” means an amount an enrollee is required to pay at the point of sale in order to receive a covered prescription drug.\n\t\t\t“Enrollee” means a policyholder, subscriber, participant, or other individual covered by a health benefit plan.\n\t\t\t“Health plan” means any health benefit plan, as defined in § 38.2-3438, that provides coverage for prescription drugs.\n\t\t\t“Pharmacy benefits management” means the administration or management of prescription drug benefits provided by a carrier for the benefit of enrollees.\n\t\t\t“Pharmacy benefits manager” means an entity that performs pharmacy benefits management. The term includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a carrier.\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":264447,"text":"No provider contract between a health carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision (i) authorizing the carrier or its pharmacy benefits manager to charge, (ii) requiring the pharmacy or pharmacist to collect, or (iii) requiring an enrollee to make, a copayment for a covered prescription drug in an amount that exceeds the least of:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":264448,"text":"The applicable copayment for the prescription drug that would be payable in the absence of this section; or","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":264449,"text":"The cash price the enrollee would pay for the prescription drug if the enrollee purchased the prescription drug without using the enrollee’s health plan.","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"C"},"4":{"id":264450,"text":"Provider contracts between a health carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain specific provisions that allow a pharmacy to:","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B2","next_prefix":"C1"},"5":{"id":264451,"text":"Disclose to an enrollee information relating to (i) the provisions of this section and (ii) the availability of a more affordable therapeutically equivalent prescription drug;","type":"section","prefixes":["C","1"],"prefix":"1","entire_prefix":"C1","prefix_anchor":"C1","level":2,"prior_prefix":"C","next_prefix":"C2"},"6":{"id":264452,"text":"Sell a more affordable therapeutically equivalent prescription drug to an enrollee if one is available in accordance with § 54.1-3408.03; and","type":"section","prefixes":["C","2"],"prefix":"2","entire_prefix":"C2","prefix_anchor":"C2","level":2,"prior_prefix":"C1","next_prefix":"C3"},"7":{"id":264453,"text":"Offer and provide direct and limited delivery services to an enrollee as an ancillary service of the pharmacy in accordance with § 54.1-3420.2.","type":"section","prefixes":["C","3"],"prefix":"3","entire_prefix":"C3","prefix_anchor":"C3","level":2,"prior_prefix":"C2","next_prefix":"D"},"8":{"id":264454,"text":"A pharmacy shall not be penalized by a pharmacy benefits manager or a carrier for discussing information or for selling a more affordable alternative as described in subsection C.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C3","next_prefix":"E"},"9":{"id":264455,"text":"Provider contracts between a health carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain specific provisions that prohibit the carrier or the pharmacy benefit manager from charging a fee to a pharmacy or otherwise holding a pharmacy responsible for a fee relating to the adjudication of a claim unless the fee is reported on the remittance advice of the adjudicated claim or is set out in contract between the pharmacy benefits manager and the pharmacy or its contracting agent.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"10":{"id":264456,"text":"This section shall not apply with respect to claims under an employee benefit plan under the Employee Retirement Income Security Act of 1974, Medicaid, or Medicare Part D.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"11":{"id":264457,"text":"This section shall apply with respect to provider contracts entered into, amended, extended, or renewed on or after January 1, 2019.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"12":{"id":264458,"text":"Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this section.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"13":{"id":264459,"text":"The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this 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nonrenewal","url":"\/38.2-3407.15_3\/","token":"38.2\/34\/1\/38.2-3407.15_3","metadata":false},"next_section":{"id":57527,"structure_id":12994,"section_number":"38.2-3407.15:5","catch_line":"Limit on cost-sharing payments for prescription insulin drugs","url":"\/38.2-3407.15_5\/","token":"38.2\/34\/1\/38.2-3407.15_5","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.15:4\/","history_text":"

This law was first created in 2018. The record of its establishment is cataloged in chapters 245<\/a> and 602<\/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":[{"id":80337,"section_number":"38.2-3407.15:6","catch_line":"Prescription drug price transparency","order_by":null,"url":"\/38.2-3407.15_6\/"},{"id":85964,"section_number":"38.2-3407.22","catch_line":"Option for rebates to enrollees; protected information","order_by":null,"url":"\/38.2-3407.22\/"},{"id":81429,"section_number":"54.1-3436.1","catch_line":"Prescription drug price transparency","order_by":null,"url":"\/54.1-3436.1\/"},{"id":75222,"section_number":"54.1-3442.02","catch_line":"Prescription drug price transparency","order_by":null,"url":"\/54.1-3442.02\/"}],"refers_to":[{"id":87496,"section_number":"38.2-223","catch_line":"Rules and regulations; orders","order_by":null,"url":"\/38.2-223\/"},{"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\/"},{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"},{"id":81842,"section_number":"54.1-3408.03","catch_line":"Dispensing of therapeutically equivalent drug product permitted","order_by":null,"url":"\/54.1-3408.03\/"}],"permalink":{"id":215015,"object_type":"law","relational_id":73491,"identifier":"38.2-3407.15:4","token":"38.2\/34\/1\/38.2-3407.15_4","url":"\/38.2-3407.15_4\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.15_4\/","token":"38.2\/34\/1\/38.2-3407.15_4","dublin_core":{"Title":"Limit on copayment for prescription drugs; permitted disclosures","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.15:4","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15<\/a>.\n\t\t\t“Copayment<\/span>” means an amount an enrollee<\/span> is required to pay at the point of sale in order<\/span> to receive a covered prescription drug.\n\t\t\t“Enrollee<\/span>” means a policyholder, subscriber, participant, or other individual covered by a health benefit plan.\n\t\t\t“Health plan<\/span>” means any health benefit plan, as defined in § 38.2-3438<\/a>, that provides coverage for prescription drugs.\n\t\t\t“Pharmacy benefits management<\/span>” means the administration or management of prescription drug benefits provided by a carrier for the benefit of enrollees<\/span>.\n\t\t\t“Pharmacy benefits manager<\/span>” means an entity that performs pharmacy benefits management<\/span>. The term includes a person<\/span> or entity acting for a pharmacy benefits manager<\/span> in a contractual or employment relationship in the performance of pharmacy benefits management<\/span> for a carrier.\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> No provider contract<\/span> between a health carrier or its pharmacy benefits manager<\/span> and a pharmacy or its contracting agent shall contain a provision (i) authorizing the carrier or its pharmacy benefits manager<\/span> to charge, (ii) requiring the pharmacy or pharmacist to collect, or (iii) requiring an enrollee<\/span> to make, a copayment<\/span> for a covered prescription drug in an amount that exceeds the least of: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The applicable copayment<\/span> for the prescription drug that would be payable in the absence of this section; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The cash price the enrollee<\/span> would pay for the prescription drug if the enrollee<\/span> purchased the prescription drug without using the enrollee<\/span>’s health plan<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Provider contracts<\/span> between a health carrier or its pharmacy benefits manager<\/span> and a pharmacy or its contracting agent shall contain specific provisions that allow a pharmacy to: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Disclose to an enrollee<\/span> information relating to (i) the provisions of this section and (ii) the availability of a more affordable therapeutically equivalent prescription drug; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Sell a more affordable therapeutically equivalent prescription drug to an enrollee<\/span> if one is available in accordance with § 54.1-3408.03<\/a>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Offer and provide direct and limited delivery services to an enrollee<\/span> as an ancillary service of the pharmacy in accordance with § 54.1-3420.2<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> A pharmacy shall not be penalized by a pharmacy benefits manager<\/span> or a carrier for discussing information or for selling a more affordable alternative as described in subsection C. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Provider contracts<\/span> between a health carrier or its pharmacy benefits manager<\/span> and a pharmacy or its contracting agent shall contain specific provisions that prohibit the carrier or the pharmacy benefit manager from charging a fee to a pharmacy or otherwise holding a pharmacy responsible for a fee relating to the adjudication of a claim unless the fee is reported on the remittance advice of the adjudicated claim or is set out in contract<\/span> between the pharmacy benefits manager<\/span> and the pharmacy or its contracting agent. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> This section shall not apply with respect to claims under an employee benefit plan under the Employee Retirement Income Security Act of 1974, Medicaid, or Medicare<\/span> Part D. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> This section shall apply with respect to provider contracts<\/span> entered into, amended, extended, or renewed on or after January 1, 2019. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> Pursuant to the authority granted by § 38.2-223<\/a>, the Commission<\/span> may promulgate such rules and regulations as it may deem necessary to implement this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> The Commission<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> individual controversies arising out of this section. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nLIMIT ON COPAYMENT FOR PRESCRIPTION DRUGS; PERMITTED DISCLOSURES (\u00a7\n38.2-3407.15:4)\n\nA. As used in this section:\n\t\t\t“Carrier” has the same meaning ascribed thereto in subsection A\nof § 38.2-3407.15.\n\t\t\t“Copayment” means an amount an enrollee is required to pay at the\npoint of sale in order to receive a covered prescription drug.\n\t\t\t“Enrollee” means a policyholder, subscriber, participant, or\nother individual covered by a health benefit plan.\n\t\t\t“Health plan” means any health benefit plan, as defined in §\n38.2-3438, that provides coverage for prescription drugs.\n\t\t\t“Pharmacy benefits management” means the administration or\nmanagement of prescription drug benefits provided by a carrier for the benefit\nof enrollees.\n\t\t\t“Pharmacy benefits manager” means an entity that performs\npharmacy benefits management. The term includes a person or entity acting for a\npharmacy benefits manager in a contractual or employment relationship in the\nperformance of pharmacy benefits management for a carrier.\n\t\t\t“Provider contract” has the same meaning ascribed thereto in\nsubsection A of § 38.2-3407.15.\n\nB. No provider contract between a health carrier or its pharmacy benefits\nmanager and a pharmacy or its contracting agent shall contain a provision (i)\nauthorizing the carrier or its pharmacy benefits manager to charge, (ii)\nrequiring the pharmacy or pharmacist to collect, or (iii) requiring an enrollee\nto make, a copayment for a covered prescription drug in an amount that exceeds\nthe least of:\n\n 1. The applicable copayment for the prescription drug that would be payable in\n the absence of this section; or\n\n 2. The cash price the enrollee would pay for the prescription drug if the\n enrollee purchased the prescription drug without using the enrollee’s\n health plan.\n\nC. Provider contracts between a health carrier or its pharmacy benefits manager\nand a pharmacy or its contracting agent shall contain specific provisions that\nallow a pharmacy to:\n\n 1. Disclose to an enrollee information relating to (i) the provisions of this\n section and (ii) the availability of a more affordable therapeutically\n equivalent prescription drug;\n\n 2. Sell a more affordable therapeutically equivalent prescription drug to an\n enrollee if one is available in accordance with § 54.1-3408.03; and\n\n 3. Offer and provide direct and limited delivery services to an enrollee as an\n ancillary service of the pharmacy in accordance with § 54.1-3420.2.\n\nD. A pharmacy shall not be penalized by a pharmacy benefits manager or a carrier\nfor discussing information or for selling a more affordable alternative as\ndescribed in subsection C.\n\nE. Provider contracts between a health carrier or its pharmacy benefits manager\nand a pharmacy or its contracting agent shall contain specific provisions that\nprohibit the carrier or the pharmacy benefit manager from charging a fee to a\npharmacy or otherwise holding a pharmacy responsible for a fee relating to the\nadjudication of a claim unless the fee is reported on the remittance advice of\nthe adjudicated claim or is set out in contract between the pharmacy benefits\nmanager and the pharmacy or its contracting agent.\n\nF. This section shall not apply with respect to claims under an employee benefit\nplan under the Employee Retirement Income Security Act of 1974, Medicaid, or\nMedicare Part D.\n\nG. This section shall apply with respect to provider contracts entered into,\namended, extended, or renewed on or after January 1, 2019.\n\nH. Pursuant to the authority granted by § 38.2-223, the Commission may\npromulgate such rules and regulations as it may deem necessary to implement this\nsection.\n\nI. The Commission shall have no jurisdiction to adjudicate individual\ncontroversies arising out of this section.\n\nHISTORY: 2018, cc. 245, 602.","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}}