{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-4312.1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-4312.1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-4312.1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-4312.1.html"}],"law_id":82617,"edition_id":1,"section_id":82617,"structure_id":12833,"section_number":"38.2-4312.1","catch_line":"Pharmacies; freedom of choice","history":"1994, c. 963; 1995, cc. 446, 467; 2010, cc. 157, 357; 2017, c. 615; 2021, Sp. Sess. I, c. 229.","full_text":"A\n\nNotwithstanding any other provision in this chapter, no health maintenance organization providing health care plans, or its pharmacy benefits manager, as defined in § 38.2-3465, shall prohibit any person receiving pharmaceutical benefits, including specialty pharmacy benefits, thereunder from selecting, without limitation, the pharmacy of his choice to furnish such benefits. This right of selection extends to and includes any pharmacy that is not a participating provider under any such health care plan and that has previously notified the health maintenance organization or its pharmacy benefits manager on its own behalf or through an intermediary, by facsimile or otherwise, of its agreement to accept reimbursement for its services at rates applicable to pharmacies that are participating providers, including any copayment consistently imposed by the plan, as payment in full. Each health maintenance organization or its pharmacy benefits manager shall permit prompt electronic or telephonic transmittal of the reimbursement agreement by the pharmacy and ensure prompt verification to the pharmacy of the terms of reimbursement. In no event shall any person receiving a covered pharmacy benefit from a nonparticipating provider that has submitted a reimbursement agreement be responsible for amounts that may be charged by the nonparticipating provider in excess of the copayment and the health maintenance organization’s reimbursement applicable to all of its participating pharmacy providers. If a pharmacy has provided notice pursuant to this subsection through an intermediary, the health maintenance organization or its intermediary may elect to respond directly to the pharmacy instead of the intermediary. Nothing in this subsection shall (i) require a health maintenance organization or its intermediary to contract with or to disclose confidential information to a pharmacy’s intermediary or (ii) prohibit a health maintenance organization or its intermediary from contracting with or disclosing confidential information to a pharmacy’s intermediary.B\n\nNo such health maintenance organization or its pharmacy benefits manager shall impose upon any person receiving pharmaceutical benefits furnished under any such health care plan:1\n\nAny copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by pharmacists who are not participating providers;2\n\nAny monetary penalty that would affect or influence any such person’s choice of pharmacy; or3\n\nAny reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are not participating providers.C\n\nFor purposes of this section, a prohibited condition or penalty shall include, without limitation: (i) denying immediate access to electronic claims filing to a pharmacy that is a nonparticipating provider and that has complied with subsection E or (ii) requiring a person receiving pharmacy benefits to make payment at point of service, except to the extent such conditions and penalties are similarly imposed on participating providers.D\n\nThe provisions of this section are not applicable to any pharmaceutical benefit covered by a health care plan when those benefits are obtained from a pharmacy wholly owned and operated by, or exclusively operated for, the health maintenance organization providing the health care plan.E\n\nAny pharmacy that wishes to be covered by this section shall, if requested to do so in writing by a health maintenance organization or its pharmacy benefits manager, within 30 days of the pharmacy’s receipt of the request, execute and deliver to the health maintenance organization or its pharmacy benefits manager, the direct service agreement or participating provider agreement that the health maintenance organization or its pharmacy benefits manager requires all of its participating providers of pharmacy benefits to execute. Any pharmacy that fails to timely execute and deliver such agreement shall not be covered by this section with respect to that health maintenance organization or its pharmacy benefits manager unless and until the pharmacy executes and delivers the agreement. No pharmacy shall be precluded from obtaining a direct service agreement or participating provider agreement for retail and specialty pharmacy if the pharmacy meets the terms and conditions of participation. Any request by a pharmacy for a direct service agreement or a participating provider agreement shall be acted upon by a health maintenance organization or its pharmacy benefits manager within 60 days of receipt of the pharmacy’s request or any subsequent submission of supplemental information if requested by the health maintenance organization or its pharmacy benefits manager.F\n\nThe Commission shall have no jurisdiction to adjudicate controversies arising out of this section.G\n\nNothing in this section shall limit the authority of a health maintenance organization providing health care plans to select a single mail order pharmacy provider as the exclusive provider of pharmacy services that are delivered to the covered person’s address by mail, common carrier, or delivery service. The provisions of this section shall not apply to such contracts. As used in this subsection, “mail order pharmacy provider” means a pharmacy permitted to conduct business in the Commonwealth whose primary business is to dispense a prescription drug or device under a prescriptive drug order and to deliver the drug or device to a patient primarily by mail, common carrier, or delivery service.","order_by":null,"text":{"0":{"id":295989,"text":"Notwithstanding any other provision in this chapter, no health maintenance organization providing health care plans, or its pharmacy benefits manager, as defined in § 38.2-3465, shall prohibit any person receiving pharmaceutical benefits, including specialty pharmacy benefits, thereunder from selecting, without limitation, the pharmacy of his choice to furnish such benefits. This right of selection extends to and includes any pharmacy that is not a participating provider under any such health care plan and that has previously notified the health maintenance organization or its pharmacy benefits manager on its own behalf or through an intermediary, by facsimile or otherwise, of its agreement to accept reimbursement for its services at rates applicable to pharmacies that are participating providers, including any copayment consistently imposed by the plan, as payment in full. Each health maintenance organization or its pharmacy benefits manager shall permit prompt electronic or telephonic transmittal of the reimbursement agreement by the pharmacy and ensure prompt verification to the pharmacy of the terms of reimbursement. In no event shall any person receiving a covered pharmacy benefit from a nonparticipating provider that has submitted a reimbursement agreement be responsible for amounts that may be charged by the nonparticipating provider in excess of the copayment and the health maintenance organization’s reimbursement applicable to all of its participating pharmacy providers. If a pharmacy has provided notice pursuant to this subsection through an intermediary, the health maintenance organization or its intermediary may elect to respond directly to the pharmacy instead of the intermediary. Nothing in this subsection shall (i) require a health maintenance organization or its intermediary to contract with or to disclose confidential information to a pharmacy’s intermediary or (ii) prohibit a health maintenance organization or its intermediary from contracting with or disclosing confidential information to a pharmacy’s intermediary.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":295990,"text":"No such health maintenance organization or its pharmacy benefits manager shall impose upon any person receiving pharmaceutical benefits furnished under any such health care plan:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":295991,"text":"Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by pharmacists who are not participating providers;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":295992,"text":"Any monetary penalty that would affect or influence any such person’s choice of pharmacy; or","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":295993,"text":"Any reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are not participating providers.","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"C"},"5":{"id":295994,"text":"For purposes of this section, a prohibited condition or penalty shall include, without limitation: (i) denying immediate access to electronic claims filing to a pharmacy that is a nonparticipating provider and that has complied with subsection E or (ii) requiring a person receiving pharmacy benefits to make payment at point of service, except to the extent such conditions and penalties are similarly imposed on participating providers.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B3","next_prefix":"D"},"6":{"id":295995,"text":"The provisions of this section are not applicable to any pharmaceutical benefit covered by a health care plan when those benefits are obtained from a pharmacy wholly owned and operated by, or exclusively operated for, the health maintenance organization providing the health care plan.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"7":{"id":295996,"text":"Any pharmacy that wishes to be covered by this section shall, if requested to do so in writing by a health maintenance organization or its pharmacy benefits manager, within 30 days of the pharmacy’s receipt of the request, execute and deliver to the health maintenance organization or its pharmacy benefits manager, the direct service agreement or participating provider agreement that the health maintenance organization or its pharmacy benefits manager requires all of its participating providers of pharmacy benefits to execute. Any pharmacy that fails to timely execute and deliver such agreement shall not be covered by this section with respect to that health maintenance organization or its pharmacy benefits manager unless and until the pharmacy executes and delivers the agreement. No pharmacy shall be precluded from obtaining a direct service agreement or participating provider agreement for retail and specialty pharmacy if the pharmacy meets the terms and conditions of participation. Any request by a pharmacy for a direct service agreement or a participating provider agreement shall be acted upon by a health maintenance organization or its pharmacy benefits manager within 60 days of receipt of the pharmacy’s request or any subsequent submission of supplemental information if requested by the health maintenance organization or its pharmacy benefits manager.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"8":{"id":295997,"text":"The Commission shall have no jurisdiction to adjudicate controversies arising out of this section.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"9":{"id":295998,"text":"Nothing in this section shall limit the authority of a health maintenance organization providing health care plans to select a single mail order pharmacy provider as the exclusive provider of pharmacy services that are delivered to the covered person’s address by mail, common carrier, or delivery service. The provisions of this section shall not apply to such contracts. As used in this subsection, “mail order pharmacy provider” means a pharmacy permitted to conduct business in the Commonwealth whose primary business is to dispense a prescription drug or device under a prescriptive drug order and to deliver the drug or device to a patient primarily by mail, common carrier, or delivery service.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F"}},"ancestry":[{"id":12833,"edition_id":1,"name":"Health Maintenance Organizations","identifier":"43","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:43:55","date_modified":"2026-06-26 03:43:55","permalink":{"id":216835,"object_type":"structure","relational_id":12833,"identifier":"43","token":"38.2\/43","url":"\/38.2\/43\/","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":72005,"structure_id":12833,"section_number":"38.2-4300","catch_line":"Definitions","url":"\/38.2-4300\/","token":"38.2\/43\/38.2-4300","metadata":false},{"id":80882,"structure_id":12833,"section_number":"38.2-4301","catch_line":"Establishment of health maintenance organizations","url":"\/38.2-4301\/","token":"38.2\/43\/38.2-4301","metadata":false},{"id":64417,"structure_id":12833,"section_number":"38.2-4302","catch_line":"Issuance of license; fee; minimum net worth; impairment","url":"\/38.2-4302\/","token":"38.2\/43\/38.2-4302","metadata":false},{"id":73205,"structure_id":12833,"section_number":"38.2-4303","catch_line":"Powers","url":"\/38.2-4303\/","token":"38.2\/43\/38.2-4303","metadata":false},{"id":68216,"structure_id":12833,"section_number":"38.2-4304","catch_line":"Governing body","url":"\/38.2-4304\/","token":"38.2\/43\/38.2-4304","metadata":false},{"id":54130,"structure_id":12833,"section_number":"38.2-4305","catch_line":"Fiduciary responsibilities","url":"\/38.2-4305\/","token":"38.2\/43\/38.2-4305","metadata":false},{"id":81322,"structure_id":12833,"section_number":"38.2-4306","catch_line":"Evidence of coverage and charges for health care services","url":"\/38.2-4306\/","token":"38.2\/43\/38.2-4306","metadata":false},{"id":73640,"structure_id":12833,"section_number":"38.2-4306.1","catch_line":"Interest on claim proceeds","url":"\/38.2-4306.1\/","token":"38.2\/43\/38.2-4306.1","metadata":false},{"id":65829,"structure_id":12833,"section_number":"38.2-4307","catch_line":"Annual statement","url":"\/38.2-4307\/","token":"38.2\/43\/38.2-4307","metadata":false},{"id":85130,"structure_id":12833,"section_number":"38.2-4307.1","catch_line":"Additional reports","url":"\/38.2-4307.1\/","token":"38.2\/43\/38.2-4307.1","metadata":false},{"id":77610,"structure_id":12833,"section_number":"38.2-4308","catch_line":"Repealed","url":"\/38.2-4308\/","token":"38.2\/43\/38.2-4308","metadata":false},{"id":80159,"structure_id":12833,"section_number":"38.2-4309","catch_line":"Investments","url":"\/38.2-4309\/","token":"38.2\/43\/38.2-4309","metadata":false},{"id":84555,"structure_id":12833,"section_number":"38.2-4310","catch_line":"Protection against insolvency","url":"\/38.2-4310\/","token":"38.2\/43\/38.2-4310","metadata":false},{"id":59833,"structure_id":12833,"section_number":"38.2-4310.1","catch_line":"Deposits","url":"\/38.2-4310.1\/","token":"38.2\/43\/38.2-4310.1","metadata":false},{"id":53983,"structure_id":12833,"section_number":"38.2-4311","catch_line":"Repealed","url":"\/38.2-4311\/","token":"38.2\/43\/38.2-4311","metadata":false},{"id":62703,"structure_id":12833,"section_number":"38.2-4312","catch_line":"Prohibited practices","url":"\/38.2-4312\/","token":"38.2\/43\/38.2-4312","metadata":false},{"id":82617,"structure_id":12833,"section_number":"38.2-4312.1","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-4312.1\/","token":"38.2\/43\/38.2-4312.1","metadata":false},{"id":71246,"structure_id":12833,"section_number":"38.2-4312.2","catch_line":"Repealed","url":"\/38.2-4312.2\/","token":"38.2\/43\/38.2-4312.2","metadata":false},{"id":79585,"structure_id":12833,"section_number":"38.2-4312.3","catch_line":"Patient access to emergency services","url":"\/38.2-4312.3\/","token":"38.2\/43\/38.2-4312.3","metadata":false},{"id":70762,"structure_id":12833,"section_number":"38.2-4313","catch_line":"Licensing of agents","url":"\/38.2-4313\/","token":"38.2\/43\/38.2-4313","metadata":false},{"id":73994,"structure_id":12833,"section_number":"38.2-4314","catch_line":"Powers of insurers and health services plans","url":"\/38.2-4314\/","token":"38.2\/43\/38.2-4314","metadata":false},{"id":60856,"structure_id":12833,"section_number":"38.2-4315","catch_line":"Examinations","url":"\/38.2-4315\/","token":"38.2\/43\/38.2-4315","metadata":false},{"id":61029,"structure_id":12833,"section_number":"38.2-4316","catch_line":"Suspension or revocation of license","url":"\/38.2-4316\/","token":"38.2\/43\/38.2-4316","metadata":false},{"id":82370,"structure_id":12833,"section_number":"38.2-4317","catch_line":"Repealed","url":"\/38.2-4317\/","token":"38.2\/43\/38.2-4317","metadata":false},{"id":84618,"structure_id":12833,"section_number":"38.2-4318","catch_line":"License renewals","url":"\/38.2-4318\/","token":"38.2\/43\/38.2-4318","metadata":false},{"id":67952,"structure_id":12833,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","url":"\/38.2-4319\/","token":"38.2\/43\/38.2-4319","metadata":false},{"id":74856,"structure_id":12833,"section_number":"38.2-4320","catch_line":"Authority of Commonwealth to contract with health maintenance organizations","url":"\/38.2-4320\/","token":"38.2\/43\/38.2-4320","metadata":false},{"id":74357,"structure_id":12833,"section_number":"38.2-4320.1","catch_line":"Explanation of benefits for health maintenance organization enrollees who are recipients of medical assistance services or covered by the Family Access to Medical Insurance Security (FAMIS) Plan","url":"\/38.2-4320.1\/","token":"38.2\/43\/38.2-4320.1","metadata":false},{"id":74331,"structure_id":12833,"section_number":"38.2-4321","catch_line":"Health maintenance organization affected by chapter","url":"\/38.2-4321\/","token":"38.2\/43\/38.2-4321","metadata":false},{"id":63129,"structure_id":12833,"section_number":"38.2-4322","catch_line":"Affiliation period","url":"\/38.2-4322\/","token":"38.2\/43\/38.2-4322","metadata":false},{"id":67176,"structure_id":12833,"section_number":"38.2-4323","catch_line":"Alternative methods","url":"\/38.2-4323\/","token":"38.2\/43\/38.2-4323","metadata":false}],"previous_section":{"id":62703,"structure_id":12833,"section_number":"38.2-4312","catch_line":"Prohibited practices","url":"\/38.2-4312\/","token":"38.2\/43\/38.2-4312","metadata":false},"next_section":{"id":71246,"structure_id":12833,"section_number":"38.2-4312.2","catch_line":"Repealed","url":"\/38.2-4312.2\/","token":"38.2\/43\/38.2-4312.2","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-4312.1\/","history_text":"

This law was first created in 1994. The record of its establishment is cataloged in chapter 963<\/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. It has been modified 3 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 1995, chapters 446<\/a> and 467<\/a>; in 2010, chapters 157<\/a> and 357<\/a>; in 2017, chapter 615<\/a>.<\/p>","references":[{"id":68442,"section_number":"38.2-3407.12","catch_line":"Patient optional point-of-service benefit","order_by":null,"url":"\/38.2-3407.12\/"},{"id":62232,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","order_by":null,"url":"\/38.2-3407.9_01\/"}],"refers_to":[{"id":60000,"section_number":"38.2-3465","catch_line":"Definitions","order_by":null,"url":"\/38.2-3465\/"}],"permalink":{"id":216901,"object_type":"law","relational_id":82617,"identifier":"38.2-4312.1","token":"38.2\/43\/38.2-4312.1","url":"\/38.2-4312.1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-4312.1\/","token":"38.2\/43\/38.2-4312.1","dublin_core":{"Title":"Pharmacies; freedom of choice","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-4312.1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Notwithstanding any other provision in this chapter, no health maintenance organization<\/span> providing health care plans<\/span>, or its pharmacy benefits manager, as defined in § 38.2-3465<\/a>, shall prohibit any person<\/span> receiving pharmaceutical benefits, including specialty pharmacy benefits, thereunder from selecting, without limitation, the pharmacy of his choice to furnish such benefits. This right of selection extends to and includes any pharmacy that is not a participating provider<\/span> under any such health care plan<\/span> and that has previously notified the health maintenance organization<\/span> or its pharmacy benefits manager on its own behalf or through an intermediary, by facsimile or otherwise, of its agreement to accept reimbursement for its services at rates<\/span><\/span> applicable to pharmacies that are participating providers<\/span>, including any copayment<\/span> consistently imposed by the plan, as payment in full. Each health maintenance organization<\/span> or its pharmacy benefits manager shall permit prompt electronic or telephonic transmittal of the reimbursement agreement by the pharmacy and ensure prompt verification to the pharmacy of the terms of reimbursement. In no event shall any person<\/span> receiving a covered pharmacy benefit from a nonparticipating provider that has submitted a reimbursement agreement be responsible for amounts that may be charged by the nonparticipating provider in excess of the copayment<\/span> and the health maintenance organization<\/span>’s reimbursement applicable to all of its participating pharmacy providers. If a pharmacy has provided notice pursuant to this subsection through an intermediary, the health maintenance organization<\/span> or its intermediary may elect to respond directly to the pharmacy instead of the intermediary. Nothing in this subsection shall (i) require a health maintenance organization<\/span> or its intermediary to contract<\/span> with or to disclose confidential information to a pharmacy’s intermediary or (ii) prohibit a health maintenance organization<\/span> or its intermediary from contracting with or disclosing confidential information to a pharmacy’s intermediary. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> No such health maintenance organization<\/span> or its pharmacy benefits manager shall impose upon any person<\/span> receiving pharmaceutical benefits furnished under any such health care plan<\/span>: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Any copayment<\/span>, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment<\/span> level, whether or not such benefits are furnished by pharmacists who are not participating providers<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Any monetary penalty<\/span> that would affect or influence any such person<\/span>’s choice of pharmacy; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Any reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are not participating providers<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> For purposes of this section, a prohibited condition or penalty<\/span> shall include, without limitation: (i) denying immediate access to electronic claims filing to a pharmacy that is a nonparticipating provider and that has complied with subsection E or (ii) requiring a person<\/span> receiving pharmacy benefits to make payment at point of service, except to the extent such conditions and penalties are similarly imposed on participating providers<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The provisions of this section are not applicable to any pharmaceutical benefit covered by a health care plan<\/span> when those benefits are obtained from a pharmacy wholly owned and operated by, or exclusively operated for, the health maintenance organization<\/span> providing the health care plan<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Any pharmacy that wishes to be covered by this section shall, if requested to do so in writing by a health maintenance organization<\/span> or its pharmacy benefits manager, within 30 days of the pharmacy’s receipt of the request, execute and deliver to the health maintenance organization<\/span> or its pharmacy benefits manager, the direct service agreement or participating provider<\/span> agreement that the health maintenance organization<\/span> or its pharmacy benefits manager requires all of its participating providers<\/span> of pharmacy benefits to execute. Any pharmacy that fails to timely execute and deliver such agreement shall not be covered by this section with respect to that health maintenance organization<\/span> or its pharmacy benefits manager unless and until the pharmacy executes and delivers the agreement. No pharmacy shall be precluded from obtaining a direct service agreement or participating provider<\/span> agreement for retail and specialty pharmacy if the pharmacy meets the terms and conditions of participation. Any request by a pharmacy for a direct service agreement or a participating provider<\/span> agreement shall be acted upon by a health maintenance organization<\/span> or its pharmacy benefits manager within 60 days of receipt of the pharmacy’s request or any subsequent submission of supplemental information if requested by the health maintenance organization<\/span> or its pharmacy benefits manager. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

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

G.<\/span> Nothing in this section shall limit the authority of a health maintenance organization<\/span> providing health care plans<\/span> to select a single mail order pharmacy provider<\/span> as the exclusive provider of pharmacy services that are delivered to the covered person<\/span>’s address by mail, common carrier, or delivery service. The provisions of this section shall not apply to such contracts<\/span>. As used in this subsection, “mail order pharmacy provider<\/span>” means a pharmacy permitted to conduct business in the Commonwealth whose primary business is to dispense a prescription drug or device under a prescriptive drug order and to deliver the drug or device to a patient primarily by mail, common carrier, or delivery service. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nPHARMACIES; FREEDOM OF CHOICE (\u00a7 38.2-4312.1)\n\nA. Notwithstanding any other provision in this chapter, no health maintenance\norganization providing health care plans, or its pharmacy benefits manager, as\ndefined in § 38.2-3465, shall prohibit any person receiving pharmaceutical\nbenefits, including specialty pharmacy benefits, thereunder from selecting,\nwithout limitation, the pharmacy of his choice to furnish such benefits. This\nright of selection extends to and includes any pharmacy that is not a\nparticipating provider under any such health care plan and that has previously\nnotified the health maintenance organization or its pharmacy benefits manager on\nits own behalf or through an intermediary, by facsimile or otherwise, of its\nagreement to accept reimbursement for its services at rates applicable to\npharmacies that are participating providers, including any copayment\nconsistently imposed by the plan, as payment in full. Each health maintenance\norganization or its pharmacy benefits manager shall permit prompt electronic or\ntelephonic transmittal of the reimbursement agreement by the pharmacy and ensure\nprompt verification to the pharmacy of the terms of reimbursement. In no event\nshall any person receiving a covered pharmacy benefit from a nonparticipating\nprovider that has submitted a reimbursement agreement be responsible for amounts\nthat may be charged by the nonparticipating provider in excess of the copayment\nand the health maintenance organization’s reimbursement applicable to all\nof its participating pharmacy providers. If a pharmacy has provided notice\npursuant to this subsection through an intermediary, the health maintenance\norganization or its intermediary may elect to respond directly to the pharmacy\ninstead of the intermediary. Nothing in this subsection shall (i) require a\nhealth maintenance organization or its intermediary to contract with or to\ndisclose confidential information to a pharmacy’s intermediary or (ii)\nprohibit a health maintenance organization or its intermediary from contracting\nwith or disclosing confidential information to a pharmacy’s intermediary.\n\nB. No such health maintenance organization or its pharmacy benefits manager\nshall impose upon any person receiving pharmaceutical benefits furnished under\nany such health care plan:\n\n 1. Any copayment, fee or condition that is not equally imposed upon all\n individuals in the same benefit category, class or copayment level, whether or\n not such benefits are furnished by pharmacists who are not participating\n providers;\n\n 2. Any monetary penalty that would affect or influence any such person’s\n choice of pharmacy; or\n\n 3. Any reduction in allowable reimbursement for pharmacy services related to\n utilization of pharmacists who are not participating providers.\n\nC. For purposes of this section, a prohibited condition or penalty shall\ninclude, without limitation: (i) denying immediate access to electronic claims\nfiling to a pharmacy that is a nonparticipating provider and that has complied\nwith subsection E or (ii) requiring a person receiving pharmacy benefits to make\npayment at point of service, except to the extent such conditions and penalties\nare similarly imposed on participating providers.\n\nD. The provisions of this section are not applicable to any pharmaceutical\nbenefit covered by a health care plan when those benefits are obtained from a\npharmacy wholly owned and operated by, or exclusively operated for, the health\nmaintenance organization providing the health care plan.\n\nE. Any pharmacy that wishes to be covered by this section shall, if requested to\ndo so in writing by a health maintenance organization or its pharmacy benefits\nmanager, within 30 days of the pharmacy’s receipt of the request, execute\nand deliver to the health maintenance organization or its pharmacy benefits\nmanager, the direct service agreement or participating provider agreement that\nthe health maintenance organization or its pharmacy benefits manager requires\nall of its participating providers of pharmacy benefits to execute. Any pharmacy\nthat fails to timely execute and deliver such agreement shall not be covered by\nthis section with respect to that health maintenance organization or its\npharmacy benefits manager unless and until the pharmacy executes and delivers\nthe agreement. No pharmacy shall be precluded from obtaining a direct service\nagreement or participating provider agreement for retail and specialty pharmacy\nif the pharmacy meets the terms and conditions of participation. Any request by\na pharmacy for a direct service agreement or a participating provider agreement\nshall be acted upon by a health maintenance organization or its pharmacy\nbenefits manager within 60 days of receipt of the pharmacy’s request or\nany subsequent submission of supplemental information if requested by the health\nmaintenance organization or its pharmacy benefits manager.\n\nF. The Commission shall have no jurisdiction to adjudicate controversies arising\nout of this section.\n\nG. Nothing in this section shall limit the authority of a health maintenance\norganization providing health care plans to select a single mail order pharmacy\nprovider as the exclusive provider of pharmacy services that are delivered to\nthe covered person’s address by mail, common carrier, or delivery service.\nThe provisions of this section shall not apply to such contracts. As used in\nthis subsection, “mail order pharmacy provider” means a pharmacy\npermitted to conduct business in the Commonwealth whose primary business is to\ndispense a prescription drug or device under a prescriptive drug order and to\ndeliver the drug or device to a patient primarily by mail, common carrier, or\ndelivery service.\n\nHISTORY: 1994, c. 963; 1995, cc. 446, 467; 2010, cc. 157, 357; 2017, c. 615;\n2021, Sp. Sess. I, c. 229.","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}}