{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.15_5.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.15_5.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.15_5.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.15_5.html"}],"law_id":57527,"edition_id":1,"section_id":57527,"structure_id":12994,"section_number":"38.2-3407.15:5","catch_line":"Limit on cost-sharing payments for prescription insulin drugs","history":"2020, c. 881.","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“Cost-sharing payment” means the total amount a covered person is required to pay at the point of sale in order to receive a prescription drug that is covered under the covered person’s health plan.\n\t\t\t“Covered person” means a policyholder, subscriber, participant, or other individual covered by a health plan.\n\t\t\t“Health plan” means any health benefit plan, as defined in § 38.2-3438, that provides coverage for a prescription insulin drug.\n\t\t\t“Pharmacy benefits manager” means an entity that engages in the administration or management of prescription drug benefits provided by a carrier for the benefit of its covered persons.\n\t\t\t“Prescription insulin drug” means a prescription drug that contains insulin and is used to treat diabetes.\n\t\t\t“Provider contract” has the same meaning ascribed thereto in subsection A of § 38.2-3407.15.B\n\nEvery health plan offered by a carrier shall set the cost-sharing payment that a covered person is required to pay for a covered prescription insulin drug at an amount that does not exceed $50 per 30-day supply of the prescription insulin drug, regardless of the amount or type of insulin needed to fill the covered person’s prescription.C\n\nNothing in this section shall prevent a carrier from setting a covered person’s cost-sharing payment for a covered prescription insulin drug at an amount that is less than the maximum amount permitted pursuant to subsection B.D\n\nNo provider contract between a carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision (i) authorizing the carrier’s pharmacy benefits manager or the pharmacy to charge, (ii) requiring the pharmacy to collect, or (iii) requiring a covered person to make a cost-sharing payment for a covered prescription insulin drug in an amount that exceeds the amount of the cost-sharing payment for the covered prescription insulin drug established by the carrier pursuant to subsection B.E\n\nThis section shall apply with respect to health plans and provider contracts entered into, amended, extended, or renewed on or after January 1, 2021.F\n\nPursuant to the authority granted by § 38.2-223, the Commission may adopt such rules and regulations as it may deem necessary to implement this section.","order_by":null,"text":{"0":{"id":210772,"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“Cost-sharing payment” means the total amount a covered person is required to pay at the point of sale in order to receive a prescription drug that is covered under the covered person’s health plan.\n\t\t\t“Covered person” means a policyholder, subscriber, participant, or other individual covered by a health plan.\n\t\t\t“Health plan” means any health benefit plan, as defined in § 38.2-3438, that provides coverage for a prescription insulin drug.\n\t\t\t“Pharmacy benefits manager” means an entity that engages in the administration or management of prescription drug benefits provided by a carrier for the benefit of its covered persons.\n\t\t\t“Prescription insulin drug” means a prescription drug that contains insulin and is used to treat diabetes.\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":210773,"text":"Every health plan offered by a carrier shall set the cost-sharing payment that a covered person is required to pay for a covered prescription insulin drug at an amount that does not exceed $50 per 30-day supply of the prescription insulin drug, regardless of the amount or type of insulin needed to fill the covered person’s prescription.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":210774,"text":"Nothing in this section shall prevent a carrier from setting a covered person’s cost-sharing payment for a covered prescription insulin drug at an amount that is less than the maximum amount permitted pursuant to subsection B.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":210775,"text":"No provider contract between a carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision (i) authorizing the carrier’s pharmacy benefits manager or the pharmacy to charge, (ii) requiring the pharmacy to collect, or (iii) requiring a covered person to make a cost-sharing payment for a covered prescription insulin drug in an amount that exceeds the amount of the cost-sharing payment for the covered prescription insulin drug established by the carrier pursuant to subsection B.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":210776,"text":"This section shall apply with respect to health plans and provider contracts entered into, amended, extended, or renewed on or after January 1, 2021.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":210777,"text":"Pursuant to the authority granted by § 38.2-223, the Commission may adopt such rules and regulations as it may deem necessary to implement this section.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E"}},"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; limitations on disclosure of medical treatment options prohibited","url":"\/38.2-3405\/","token":"38.2\/34\/1\/38.2-3405","metadata":false},{"id":84136,"structure_id":12994,"section_number":"38.2-3405.1","catch_line":"Commonwealth's right to certain accident and sickness benefits","url":"\/38.2-3405.1\/","token":"38.2\/34\/1\/38.2-3405.1","metadata":false},{"id":70730,"structure_id":12994,"section_number":"38.2-3406","catch_line":"Accident and sickness benefits not subject to legal process","url":"\/38.2-3406\/","token":"38.2\/34\/1\/38.2-3406","metadata":false},{"id":84333,"structure_id":12994,"section_number":"38.2-3406.1","catch_line":"Application of requirements that policies offered by small employers include state-mandated health benefits","url":"\/38.2-3406.1\/","token":"38.2\/34\/1\/38.2-3406.1","metadata":false},{"id":67972,"structure_id":12994,"section_number":"38.2-3406.2","catch_line":"Capped benefits under insurance policies and contracts","url":"\/38.2-3406.2\/","token":"38.2\/34\/1\/38.2-3406.2","metadata":false},{"id":76321,"structure_id":12994,"section_number":"38.2-3407","catch_line":"Health benefit programs","url":"\/38.2-3407\/","token":"38.2\/34\/1\/38.2-3407","metadata":false},{"id":66921,"structure_id":12994,"section_number":"38.2-3407.1","catch_line":"Interest on accident and sickness claim proceeds","url":"\/38.2-3407.1\/","token":"38.2\/34\/1\/38.2-3407.1","metadata":false},{"id":58079,"structure_id":12994,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","url":"\/38.2-3407.10\/","token":"38.2\/34\/1\/38.2-3407.10","metadata":false},{"id":66411,"structure_id":12994,"section_number":"38.2-3407.10:1","catch_line":"Processing of new provider applications and reimbursement for services rendered during pendency of a participating provider's credentialing application","url":"\/38.2-3407.10_1\/","token":"38.2\/34\/1\/38.2-3407.10_1","metadata":false},{"id":56463,"structure_id":12994,"section_number":"38.2-3407.10:2","catch_line":"Credentialing of private mental health agencies","url":"\/38.2-3407.10_2\/","token":"38.2\/34\/1\/38.2-3407.10_2","metadata":false},{"id":82372,"structure_id":12994,"section_number":"38.2-3407.11","catch_line":"Access to obstetrician-gynecologists","url":"\/38.2-3407.11\/","token":"38.2\/34\/1\/38.2-3407.11","metadata":false},{"id":70024,"structure_id":12994,"section_number":"38.2-3407.11:1","catch_line":"Access to specialists; standing referrals","url":"\/38.2-3407.11_1\/","token":"38.2\/34\/1\/38.2-3407.11_1","metadata":false},{"id":71393,"structure_id":12994,"section_number":"38.2-3407.11:2","catch_line":"Standing referral for cancer patients","url":"\/38.2-3407.11_2\/","token":"38.2\/34\/1\/38.2-3407.11_2","metadata":false},{"id":72434,"structure_id":12994,"section_number":"38.2-3407.11:3","catch_line":"Breast cancer underwriting and preexisting condition restrictions","url":"\/38.2-3407.11_3\/","token":"38.2\/34\/1\/38.2-3407.11_3","metadata":false},{"id":64402,"structure_id":12994,"section_number":"38.2-3407.11:4","catch_line":"Disability arising out of childbirth; minimum benefit","url":"\/38.2-3407.11_4\/","token":"38.2\/34\/1\/38.2-3407.11_4","metadata":false},{"id":66706,"structure_id":12994,"section_number":"38.2-3407.11:5","catch_line":"Interhospital transfer for newborn or mother; prior authorization prohibited","url":"\/38.2-3407.11_5\/","token":"38.2\/34\/1\/38.2-3407.11_5","metadata":false},{"id":68442,"structure_id":12994,"section_number":"38.2-3407.12","catch_line":"Patient optional point-of-service benefit","url":"\/38.2-3407.12\/","token":"38.2\/34\/1\/38.2-3407.12","metadata":false},{"id":81634,"structure_id":12994,"section_number":"38.2-3407.13","catch_line":"Refusal to accept assignments prohibited; dentists and oral surgeons","url":"\/38.2-3407.13\/","token":"38.2\/34\/1\/38.2-3407.13","metadata":false},{"id":79541,"structure_id":12994,"section_number":"38.2-3407.13:1","catch_line":"Coordination of benefits; notice of priority of coverage","url":"\/38.2-3407.13_1\/","token":"38.2\/34\/1\/38.2-3407.13_1","metadata":false},{"id":87429,"structure_id":12994,"section_number":"38.2-3407.13:2","catch_line":"Claims paid to insureds for services from nonparticipating physicians","url":"\/38.2-3407.13_2\/","token":"38.2\/34\/1\/38.2-3407.13_2","metadata":false},{"id":60288,"structure_id":12994,"section_number":"38.2-3407.14","catch_line":"Notice of premium or deductible increases","url":"\/38.2-3407.14\/","token":"38.2\/34\/1\/38.2-3407.14","metadata":false},{"id":82945,"structure_id":12994,"section_number":"38.2-3407.14:1","catch_line":"Standard of clinical evidence for decisions on coverage for proton radiation therapy","url":"\/38.2-3407.14_1\/","token":"38.2\/34\/1\/38.2-3407.14_1","metadata":false},{"id":71060,"structure_id":12994,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","url":"\/38.2-3407.15\/","token":"38.2\/34\/1\/38.2-3407.15","metadata":false},{"id":79973,"structure_id":12994,"section_number":"38.2-3407.15:1","catch_line":"Carrier contracts with pharmacy providers; required provisions; limit on termination or nonrenewal","url":"\/38.2-3407.15_1\/","token":"38.2\/34\/1\/38.2-3407.15_1","metadata":false},{"id":81930,"structure_id":12994,"section_number":"38.2-3407.15:2","catch_line":"(Effective January 1, 2027) Carrier contracts; 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},{"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","url":"\/38.2-3407.15_3\/","token":"38.2\/34\/1\/38.2-3407.15_3","metadata":false},{"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},{"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},{"id":80337,"structure_id":12994,"section_number":"38.2-3407.15:6","catch_line":"Prescription drug price transparency","url":"\/38.2-3407.15_6\/","token":"38.2\/34\/1\/38.2-3407.15_6","metadata":false},{"id":87317,"structure_id":12994,"section_number":"38.2-3407.15:7","catch_line":"Carrier provision of certain information","url":"\/38.2-3407.15_7\/","token":"38.2\/34\/1\/38.2-3407.15_7","metadata":false},{"id":82040,"structure_id":12994,"section_number":"38.2-3407.15:8","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for health care services","url":"\/38.2-3407.15_8\/","token":"38.2\/34\/1\/38.2-3407.15_8","metadata":false},{"id":76440,"structure_id":12994,"section_number":"38.2-3407.16","catch_line":"Requirements for obstetrical care","url":"\/38.2-3407.16\/","token":"38.2\/34\/1\/38.2-3407.16","metadata":false},{"id":64799,"structure_id":12994,"section_number":"38.2-3407.17","catch_line":"Payment for services by dentists and oral surgeons","url":"\/38.2-3407.17\/","token":"38.2\/34\/1\/38.2-3407.17","metadata":false},{"id":55530,"structure_id":12994,"section_number":"38.2-3407.17:1","catch_line":"Payment and reimbursement practices for dental services; network access","url":"\/38.2-3407.17_1\/","token":"38.2\/34\/1\/38.2-3407.17_1","metadata":false},{"id":81770,"structure_id":12994,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","url":"\/38.2-3407.18\/","token":"38.2\/34\/1\/38.2-3407.18","metadata":false},{"id":83502,"structure_id":12994,"section_number":"38.2-3407.19","catch_line":"Payment for services by optometrists and ophthalmologists","url":"\/38.2-3407.19\/","token":"38.2\/34\/1\/38.2-3407.19","metadata":false},{"id":77646,"structure_id":12994,"section_number":"38.2-3407.2","catch_line":"Coverage for medical child support","url":"\/38.2-3407.2\/","token":"38.2\/34\/1\/38.2-3407.2","metadata":false},{"id":73127,"structure_id":12994,"section_number":"38.2-3407.20","catch_line":"Calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement","url":"\/38.2-3407.20\/","token":"38.2\/34\/1\/38.2-3407.20","metadata":false},{"id":57407,"structure_id":12994,"section_number":"38.2-3407.21","catch_line":"Short-term limited-duration medical plans","url":"\/38.2-3407.21\/","token":"38.2\/34\/1\/38.2-3407.21","metadata":false},{"id":85964,"structure_id":12994,"section_number":"38.2-3407.22","catch_line":"Option for rebates to enrollees; protected information","url":"\/38.2-3407.22\/","token":"38.2\/34\/1\/38.2-3407.22","metadata":false},{"id":81846,"structure_id":12994,"section_number":"38.2-3407.3","catch_line":"Calculation of cost-sharing provisions","url":"\/38.2-3407.3\/","token":"38.2\/34\/1\/38.2-3407.3","metadata":false},{"id":62583,"structure_id":12994,"section_number":"38.2-3407.3:1","catch_line":"Premium payment arrearages; order of crediting payments","url":"\/38.2-3407.3_1\/","token":"38.2\/34\/1\/38.2-3407.3_1","metadata":false},{"id":78457,"structure_id":12994,"section_number":"38.2-3407.4","catch_line":"Explanation of benefits","url":"\/38.2-3407.4\/","token":"38.2\/34\/1\/38.2-3407.4","metadata":false},{"id":72294,"structure_id":12994,"section_number":"38.2-3407.4:1","catch_line":"Repealed","url":"\/38.2-3407.4_1\/","token":"38.2\/34\/1\/38.2-3407.4_1","metadata":false},{"id":57129,"structure_id":12994,"section_number":"38.2-3407.4:2","catch_line":"Requirements for prescription benefit cards","url":"\/38.2-3407.4_2\/","token":"38.2\/34\/1\/38.2-3407.4_2","metadata":false},{"id":62057,"structure_id":12994,"section_number":"38.2-3407.5","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.5\/","token":"38.2\/34\/1\/38.2-3407.5","metadata":false},{"id":54072,"structure_id":12994,"section_number":"38.2-3407.5:1","catch_line":"Coverage for prescription contraceptives","url":"\/38.2-3407.5_1\/","token":"38.2\/34\/1\/38.2-3407.5_1","metadata":false},{"id":79611,"structure_id":12994,"section_number":"38.2-3407.5:2","catch_line":"Reimbursements for dispensing hormonal contraceptives","url":"\/38.2-3407.5_2\/","token":"38.2\/34\/1\/38.2-3407.5_2","metadata":false},{"id":83778,"structure_id":12994,"section_number":"38.2-3407.6","catch_line":"Exclusion of podiatrist not permitted under certain circumstances","url":"\/38.2-3407.6\/","token":"38.2\/34\/1\/38.2-3407.6","metadata":false},{"id":74649,"structure_id":12994,"section_number":"38.2-3407.6:1","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.6_1\/","token":"38.2\/34\/1\/38.2-3407.6_1","metadata":false},{"id":72641,"structure_id":12994,"section_number":"38.2-3407.7","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-3407.7\/","token":"38.2\/34\/1\/38.2-3407.7","metadata":false},{"id":73400,"structure_id":12994,"section_number":"38.2-3407.8","catch_line":"Repealed","url":"\/38.2-3407.8\/","token":"38.2\/34\/1\/38.2-3407.8","metadata":false},{"id":72540,"structure_id":12994,"section_number":"38.2-3407.9","catch_line":"Reimbursement for emergency medical services vehicle transportation services","url":"\/38.2-3407.9\/","token":"38.2\/34\/1\/38.2-3407.9","metadata":false},{"id":62232,"structure_id":12994,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","url":"\/38.2-3407.9_01\/","token":"38.2\/34\/1\/38.2-3407.9_01","metadata":false},{"id":62074,"structure_id":12994,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","url":"\/38.2-3407.9_02\/","token":"38.2\/34\/1\/38.2-3407.9_02","metadata":false},{"id":68601,"structure_id":12994,"section_number":"38.2-3407.9:03","catch_line":"Payment of clean claims to administrators of pharmacy benefits","url":"\/38.2-3407.9_03\/","token":"38.2\/34\/1\/38.2-3407.9_03","metadata":false},{"id":56568,"structure_id":12994,"section_number":"38.2-3407.9:04","catch_line":"Medication synchronization","url":"\/38.2-3407.9_04\/","token":"38.2\/34\/1\/38.2-3407.9_04","metadata":false},{"id":71499,"structure_id":12994,"section_number":"38.2-3407.9:05","catch_line":"Step therapy protocols","url":"\/38.2-3407.9_05\/","token":"38.2\/34\/1\/38.2-3407.9_05","metadata":false}],"previous_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},"next_section":{"id":80337,"structure_id":12994,"section_number":"38.2-3407.15:6","catch_line":"Prescription drug price transparency","url":"\/38.2-3407.15_6\/","token":"38.2\/34\/1\/38.2-3407.15_6","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.15:5\/","history_text":"

This law was first created in 2020. The record of its establishment is cataloged in chapter 881<\/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":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\/"}],"permalink":{"id":215019,"object_type":"law","relational_id":57527,"identifier":"38.2-3407.15:5","token":"38.2\/34\/1\/38.2-3407.15_5","url":"\/38.2-3407.15_5\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.15_5\/","token":"38.2\/34\/1\/38.2-3407.15_5","dublin_core":{"Title":"Limit on cost-sharing payments for prescription insulin drugs","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.15:5","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“Cost-sharing payment<\/span>” means the total amount a covered person<\/span> is required to pay at the point of sale in order<\/span> to receive a prescription drug that is covered under the covered person<\/span>’s health plan<\/span>.\n\t\t\t“Covered person<\/span>” means a policyholder, subscriber, participant, or other individual covered by a health plan<\/span>.\n\t\t\t“Health plan<\/span>” means any health benefit plan, as defined in § 38.2-3438<\/a>, that provides coverage for a prescription insulin drug<\/span>.\n\t\t\t“Pharmacy benefits manager<\/span>” means an entity that engages in the administration or management of prescription drug benefits provided by a carrier for the benefit of its covered persons<\/span>.\n\t\t\t“Prescription insulin drug<\/span>” means a prescription drug that contains insulin and is used to treat diabetes.\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> Every health plan<\/span> offered by a carrier shall set the cost-sharing payment<\/span> that a covered person<\/span> is required to pay for a covered prescription insulin drug<\/span> at an amount that does not exceed $50 per 30-day supply of the prescription insulin drug<\/span>, regardless of the amount or type of insulin needed to fill the covered person<\/span>’s prescription. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Nothing in this section shall prevent a carrier from setting a covered person<\/span>’s cost-sharing payment<\/span> for a covered prescription insulin drug<\/span> at an amount that is less than the maximum amount permitted pursuant to subsection B. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> No provider contract<\/span> between a carrier or its pharmacy benefits manager<\/span> and a pharmacy or its contracting agent shall contain a provision (i) authorizing the carrier’s pharmacy benefits manager<\/span> or the pharmacy to charge, (ii) requiring the pharmacy to collect, or (iii) requiring a covered person<\/span> to make a cost-sharing payment<\/span> for a covered prescription insulin drug<\/span> in an amount that exceeds the amount of the cost-sharing payment<\/span> for the covered prescription insulin drug<\/span> established by the carrier pursuant to subsection B. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> This section shall apply with respect to health plans<\/span> and provider contracts<\/span> entered into, amended, extended, or renewed on or after January 1, 2021. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> Pursuant to the authority granted by § 38.2-223<\/a>, the Commission<\/span> may adopt such rules and regulations as it may deem necessary to implement this section. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nLIMIT ON COST-SHARING PAYMENTS FOR PRESCRIPTION INSULIN DRUGS (\u00a7\n38.2-3407.15:5)\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“Cost-sharing payment” means the total amount a covered person is\nrequired to pay at the point of sale in order to receive a prescription drug\nthat is covered under the covered person’s health plan.\n\t\t\t“Covered person” means a policyholder, subscriber, participant,\nor other individual covered by a health plan.\n\t\t\t“Health plan” means any health benefit plan, as defined in §\n38.2-3438, that provides coverage for a prescription insulin drug.\n\t\t\t“Pharmacy benefits manager” means an entity that engages in the\nadministration or management of prescription drug benefits provided by a carrier\nfor the benefit of its covered persons.\n\t\t\t“Prescription insulin drug” means a prescription drug that\ncontains insulin and is used to treat diabetes.\n\t\t\t“Provider contract” has the same meaning ascribed thereto in\nsubsection A of § 38.2-3407.15.\n\nB. Every health plan offered by a carrier shall set the cost-sharing payment\nthat a covered person is required to pay for a covered prescription insulin drug\nat an amount that does not exceed $50 per 30-day supply of the prescription\ninsulin drug, regardless of the amount or type of insulin needed to fill the\ncovered person’s prescription.\n\nC. Nothing in this section shall prevent a carrier from setting a covered\nperson’s cost-sharing payment for a covered prescription insulin drug at\nan amount that is less than the maximum amount permitted pursuant to subsection\nB.\n\nD. No provider contract between a carrier or its pharmacy benefits manager and a\npharmacy or its contracting agent shall contain a provision (i) authorizing the\ncarrier’s pharmacy benefits manager or the pharmacy to charge, (ii)\nrequiring the pharmacy to collect, or (iii) requiring a covered person to make a\ncost-sharing payment for a covered prescription insulin drug in an amount that\nexceeds the amount of the cost-sharing payment for the covered prescription\ninsulin drug established by the carrier pursuant to subsection B.\n\nE. This section shall apply with respect to health plans and provider contracts\nentered into, amended, extended, or renewed on or after January 1, 2021.\n\nF. Pursuant to the authority granted by § 38.2-223, the Commission may\nadopt such rules and regulations as it may deem necessary to implement this\nsection.\n\nHISTORY: 2020, c. 881.","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}}