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<law><site_title>Virginia Decoded</site_title><site_url>https://vacode.org</site_url><law_id>60000</law_id><section_number>38.2-3465</section_number><catch_line>Definitions</catch_line><edition url="https://vacode.org/2025/" slug="2025" current="TRUE" last_updated="">2025</edition><referred_to_by><reference>32.1-325.5</reference><reference>38.2-3407.15:7</reference><reference>38.2-3407.7</reference><reference>38.2-4209.1</reference><reference>38.2-4214</reference><reference>38.2-4312.1</reference><reference>38.2-4319</reference></referred_to_by><structure><unit label="title" level="1" order_by="1" identifier="38.2">Insurance</unit><unit label="chapter" level="2" order_by="1" identifier="34">Provisions Relating to Accident and Sickness Insurance</unit><unit label="article" level="3" order_by="1" identifier="9">Pharmacy Benefits Managers</unit></structure><text>
						<section id="A"><p><span class="prefix-number">A.</span> As used in this article, unless the context requires a different meaning:
			&#x201C;<span class="dictionary">Aggregate <span class="dictionary">retained rebate percentage</span></span>&#x201D; means the sum total dollar amount of a <span class="dictionary">pharmacy benefits manager</span>&#x2019;s <span class="dictionary">retained rebates</span> relating to all carrier clients of such <span class="dictionary">pharmacy benefits manager</span> divided by the sum total dollar amount of all rebates received by such <span class="dictionary">pharmacy benefits manager</span> relating to all such clients.
			&#x201C;Carrier&#x201D; has the same meaning ascribed thereto in subsection A of &#xA7; <a class="law" title="Ethics and fairness in carrier business practices" href="/38.2-3407.15/">38.2-3407.15</a>. However, &#x201C;carrier&#x201D; does not include a nonprofit health maintenance organization that operates as a group model whose internal pharmacy operation exclusively serves the members or patients of the nonprofit health maintenance organization.
			&#x201C;<span class="dictionary">Claim</span>&#x201D; means a request from a pharmacy or pharmacist to be reimbursed for the cost of administering, filling, or refilling a prescription for a drug or for providing a medical supply or device.
			&#x201C;<span class="dictionary">Claims processing services</span>&#x201D; means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include (i) receiving payments for pharmacist services, (ii) making payments to pharmacists or pharmacies for pharmacist services, or (iii) both receiving and making payments.
			&#x201C;<span class="dictionary">Contract pharmacy</span>&#x201D; means a pharmacy operating under contract with a 340B-<span class="dictionary">covered entity</span> to provide dispensing services to the 340B-<span class="dictionary">covered entity</span>, as described in 75 Fed. Reg. 10272 (March 5, 2010) or any superseding guidance published thereafter.
			&#x201C;<span class="dictionary">Covered entity</span>&#x201D; means an entity described in &#xA7; 340B(a)(4) of the federal Public Health Service Act, 42 U.S.C. &#xA7; 256B(a)(4).
			&#x201C;<span class="dictionary">Covered individual</span>&#x201D; means an individual receiving prescription medication coverage or reimbursement provided by a <span class="dictionary">pharmacy benefits manager</span> or a carrier under a health benefit plan.
			&#x201C;Health benefit plan&#x201D; has the same meaning ascribed thereto in &#xA7; <a class="law" title="Definitions" href="/38.2-3438/">38.2-3438</a>.
			&#x201C;<span class="dictionary">Mail order pharmacy</span>&#x201D; means a pharmacy whose primary business is to receive prescriptions by mail or through electronic submissions and to dispense medication to <span class="dictionary">covered individuals</span> through the use of the United <span class="dictionary">States</span> mail or other common or contract carrier services and that provides any consultation with <span class="dictionary">covered individuals</span> electronically rather than face-to-face.
			&#x201C;<span class="dictionary">Pharmacy benefits management</span>&#x201D; means the administration or management of prescription drug benefits provided by a carrier for the benefit of <span class="dictionary">covered individuals</span>. &#x201C;<span class="dictionary">Pharmacy benefits management</span>&#x201D; does not include any service provided by a nonprofit health maintenance organization that operates as a group model provided that the service is furnished through the internal pharmacy operation exclusively serves the members or patients of the nonprofit health maintenance organization.
			&#x201C;<span class="dictionary">Pharmacy benefits manager</span>&#x201D; or &#x201C;<span class="dictionary">PBM</span>&#x201D; means an entity that performs <span class="dictionary">pharmacy benefits management</span>. &#x201C;<span class="dictionary">Pharmacy benefits manager</span>&#x201D; includes an entity acting for a <span class="dictionary">PBM</span> in a contractual relationship in the performance of <span class="dictionary">pharmacy benefits management</span> for a carrier, nonprofit hospital, or third-<span class="dictionary">party</span> payor under a health program administered by the Commonwealth.
			&#x201C;<span class="dictionary"><span class="dictionary">Pharmacy benefits manager</span> affiliate</span>&#x201D; means a business, pharmacy, or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership interest or control with a <span class="dictionary">pharmacy benefits manager</span>.
			&#x201C;Rebate&#x201D; means a discount or other price concession, including without limitation incentives, disbursements, and reasonable estimates of a volume-based discount, or a payment that is (i) based on utilization of a prescription drug and (ii) paid by a manufacturer or third <span class="dictionary">party</span>, directly or indirectly, to a <span class="dictionary">pharmacy benefits manager</span>, pharmacy services administrative organization, or pharmacy after a <span class="dictionary">claim</span> has been processed and paid at a pharmacy.
			&#x201C;<span class="dictionary">Retail community pharmacy</span>&#x201D; means a pharmacy that is open to the public, serves walk-in customers, and makes available face-to-face consultations between licensed pharmacists and <span class="dictionary">persons</span> to whom medications are dispensed.
			&#x201C;Retained rebate&#x201D; means a rebate that is not passed on to a health benefit plan.
			&#x201C;<span class="dictionary">Retained rebate percentage</span>&#x201D; means the sum total dollar amount of a <span class="dictionary">pharmacy benefits manager</span>&#x2019;s <span class="dictionary">retained rebates</span> relating to a health benefit plan divided by the sum total dollar amount of all rebates received by such <span class="dictionary">pharmacy benefits manager</span> relating to such health benefit plan.
			&#x201C;<span class="dictionary">Spread pricing</span>&#x201D; means the model of prescription drug pricing in which the <span class="dictionary">pharmacy benefits manager</span> charges a health benefit plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the <span class="dictionary">pharmacy benefits manager</span> directly or indirectly pays the pharmacist or pharmacy for pharmacist services. <a id="paragraph-219666" class="section-permalink" href="https://vacode.org/38.2-3465/#A"><i class="fa fa-link"/></a></p></section></text><history>2020, cc. 219, 1288; 2022, c. 319; 2024, cc. 329, 626; 2025, cc. 413, 429.</history><metadata></metadata></law>
