                                 CODE OF VIRGINIA

LIMIT ON COPAYMENT FOR PRESCRIPTION DRUGS; PERMITTED DISCLOSURES (§
38.2-3407.15:4)

A. As used in this section:
			&#8220;Carrier&#8221; has the same meaning ascribed thereto in subsection A
of &#xA7; 38.2-3407.15.
			&#8220;Copayment&#8221; means an amount an enrollee is required to pay at the
point of sale in order to receive a covered prescription drug.
			&#8220;Enrollee&#8221; means a policyholder, subscriber, participant, or
other individual covered by a health benefit plan.
			&#8220;Health plan&#8221; means any health benefit plan, as defined in &#xA7;
38.2-3438, that provides coverage for prescription drugs.
			&#8220;Pharmacy benefits management&#8221; means the administration or
management of prescription drug benefits provided by a carrier for the benefit
of enrollees.
			&#8220;Pharmacy benefits manager&#8221; 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.
			&#8220;Provider contract&#8221; has the same meaning ascribed thereto in
subsection A of &#xA7; 38.2-3407.15.

B. 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:

   1. The applicable copayment for the prescription drug that would be payable in
   the absence of this section; or

   2. The cash price the enrollee would pay for the prescription drug if the
   enrollee purchased the prescription drug without using the enrollee&#8217;s
   health plan.

C. 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:

   1. 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;

   2. Sell a more affordable therapeutically equivalent prescription drug to an
   enrollee if one is available in accordance with &#xA7; 54.1-3408.03; and

   3. Offer and provide direct and limited delivery services to an enrollee as an
   ancillary service of the pharmacy in accordance with &#xA7; 54.1-3420.2.

D. 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.

E. 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.

F. 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.

G. This section shall apply with respect to provider contracts entered into,
amended, extended, or renewed on or after January 1, 2019.

H. Pursuant to the authority granted by &#xA7; 38.2-223, the Commission may
promulgate such rules and regulations as it may deem necessary to implement this
section.

I. The Commission shall have no jurisdiction to adjudicate individual
controversies arising out of this section.

HISTORY: 2018, cc. 245, 602.