CODE OF VIRGINIA

PHARMACIES; FREEDOM OF CHOICE (§ 38.2-3407.7)

A. Notwithstanding any provision of § 38.2-3407 to the contrary, no insurer
proposing to issue preferred provider policies or contracts shall prohibit any
person receiving pharmacy benefits furnished thereunder from selecting, without
limitation, the pharmacy of his choice to furnish such benefits. This right of
selection extends to and includes pharmacies that are nonpreferred providers and
that have previously notified the insurer, by facsimile or otherwise, of their
agreement to accept reimbursement for their services at rates applicable to
pharmacies that are preferred providers, including any copayment consistently
imposed by the insurer, as payment in full. Each insurer 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 nonpreferred provider which has submitted a reimbursement agreement be
responsible for amounts that may be charged by the nonpreferred provider in
excess of the copayment and the insurer’s reimbursement applicable to all
of its preferred pharmacy providers.

B. No such insurer shall impose upon any person receiving pharmaceutical
benefits furnished under any such policy or contract:

   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 nonpreferred providers;

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

   3.  Any reduction in allowable reimbursement for pharmacy services related to
   utilization of pharmacists who are nonpreferred 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 nonpreferred provider and that has complied with
subsection D 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 preferred providers.

D. Any pharmacy that wishes to be covered by this section shall, if requested to
do so in writing by an insurer, within 30 days of the pharmacy’s receipt
of the request, execute and deliver to the insurer the direct service agreement
or preferred provider agreement that the insurer requires all of its preferred
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 insurer unless and until the pharmacy executes and delivers the
agreement.

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

F. Nothing in this section shall limit the authority of an insurer proposing to
issue preferred provider policies or contracts 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.

HISTORY: 1994, c. 963; 1995, c. 467; 2010, cc. 157, 357.