                                 CODE OF VIRGINIA

PHARMACIES; FREEDOM OF CHOICE (§ 38.2-4312.1)

A. Notwithstanding any other provision in this chapter, no health maintenance
organization providing health care plans, or its pharmacy benefits manager, as
defined in &#xA7; 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&#8217;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&#8217;s intermediary or (ii)
prohibit a health maintenance organization or its intermediary from contracting
with or disclosing confidential information to a pharmacy&#8217;s intermediary.

B. 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:

   1. 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;

   2. Any monetary penalty that would affect or influence any such person&#8217;s
   choice of pharmacy; or

   3. Any reduction in allowable reimbursement for pharmacy services related to
   utilization of pharmacists who are not participating providers.

C. 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.

D. 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.

E. 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&#8217;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&#8217;s request or
any subsequent submission of supplemental information if requested by the health
maintenance organization or its pharmacy benefits manager.

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

G. 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&#8217;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, &#8220;mail order pharmacy provider&#8221; 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.

HISTORY: 1994, c. 963; 1995, cc. 446, 467; 2010, cc. 157, 357; 2017, c. 615;
2021, Sp. Sess. I, c. 229.