VA
Virginia Senate Bill SB1359

Virginia 2025 Regular Session

Virginia Senate Bill SB1359 Compare Versions

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1-OFFERED FOR CONSIDERATION 1/27/2025
1+2025 SESSION
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3+INTRODUCED
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37 SENATE BILL NO. 1359
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5-AMENDMENT IN THE NATURE OF A SUBSTITUTE
9+Offered January 13, 2025
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7-(Proposed by the Senate Committee on Commerce and Labor
11+Prefiled January 13, 2025
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9-on ________________)
13+A BILL to amend and reenact 38.2-3467 and 38.2-3469 of the Code of Virginia, relating to prohibited conduct by health carriers and pharmacy benefits managers; civil penalty; enforcement.
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11-(Patron Prior to SubstituteSenator Srinivasan)
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13-A BILL to amend the Code of Virginia by adding a section numbered 38.2-3407.7:1, relating to health insurance; retail community pharmacies; pharmacy benefits managers.
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17+PatronSrinivasan
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21+Referred to Committee on Commerce and Labor
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1725 Be it enacted by the General Assembly of Virginia:
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19-1. That the Code of Virginia is amended by adding a section numbered 38.2-3407.7:1 as follows:
27+1. That 38.2-3467 and 38.2-3469 of the Code of Virginia are amended and reenacted as follows:
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21- 38.2-3407.7:1. Access to retail community pharmacies.
29+ 38.2-3467. Prohibited conduct by carriers and pharmacy benefits managers; civil penalty.
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23-A. As used in this section:
31+A. No carrier on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager shall:
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25-"Carrier" has the same meaning as provided in 38.2-3407.15.
33+1. Cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue;
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27-"Covered individual" has the same meaning as provided in 38.2-3465.
35+2. Charge a pharmacist or pharmacy a fee related to the adjudication of a claim other than a reasonable fee for an initial claim submission;
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29-"Health benefit plan" has the same meaning as provided in 38.2-3438.
37+3. Reimburse a pharmacy or pharmacist an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services, calculated on a per-unit basis using the same generic product identifier or generic code number and reflecting all drug manufacturer's rebates, direct and indirect administrative fees, and costs and any remuneration;
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31-"Mail order pharmacy" has the same meaning as provided in 38.2-3465.
39+4. Penalize or retaliate against a pharmacist or pharmacy for exercising rights provided pursuant to the provisions of this article;
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33-"Pharmacy benefits management" has the same meaning as provided in 38.2-3465.
41+5. Impose requirements, exclusions, reimbursement terms, or other conditions on a covered entity or contract pharmacy that differ from those applied to entities or pharmacies that are not covered entities or contract pharmacies on the basis that the entity or pharmacy is a covered entity or contract pharmacy or that the entity or pharmacy dispenses 340B-covered drugs. Nothing in this subdivision shall (i) apply to drugs with an annual estimated per-patient cost exceeding $250,000 or (ii) prohibit the identification of a 340B reimbursement request; or
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35-"Pharmacy benefits manager" or "PBM" has the same meaning as provided in 38.2-3465.
43+6. Interfere with a covered individual's right to choose a pharmacy or provider, based on the pharmacy or provider's status as a covered entity or contract pharmacy;
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37-"Retail community pharmacy" has the same meaning as provided in 38.2-3465.
45+7. Require a covered individual, as a condition of payment or reimbursement, to purchase pharmacist services, including prescription drugs, exclusively through a mail-order pharmacy or retail pharmacy affiliated with a pharmacy benefits manager; or
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39-B. Each carrier shall, as applicable, (i) administer its health benefit plans in a manner consistent with the following requirements and (ii) include such requirements in each provider contract addressing the provision of pharmacy benefits management that the carrier or the carrier's pharmacy benefits manager enters into with a pharmacy or the pharmacy's contracting agent:
47+8. Prohibit or limit any covered individual from selecting a pharmacy or pharmacist of his choice that has agreed to participate in the health benefit plan according to the terms offered by the health benefit plan.
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41-1. Each covered individual shall be permitted to fill any mail order-covered prescription, at the covered individual's option, at any mail order pharmacy or network participating retail community pharmacy if the network participating retail community pharmacy agrees to accept reimbursement at a rate that is equivalent to that of the mail order pharmacy;
49+B. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall restrict participation of a pharmacy in a pharmacy network for provider accreditation standards or certification requirements if a pharmacist meets such accreditation standards or certification standards.
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43-2. The PBM or carrier shall not impose a differential copayment, additional fee, rebate, bonus, or other condition or benefit on any covered individual who elects to fill his prescription at an in-network retail community pharmacy that is not similarly imposed, charged, or remunerated at all pharmacies under contract with the PBM or carrier in the Commonwealth; and
51+C. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall include any mail order pharmacy or pharmacy benefits manager affiliate in calculating or determining network adequacy under any law or contract in the Commonwealth.
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45-3. The PBM shall expressly disclose to the carrier in the contract if the PBM retains all or a greater portion of a drug manufacturer's rebate amount or any additional direct or indirect remuneration from any third party for drugs dispensed through the PBM-owned mail order pharmacy than the PBM does for drugs dispensed through a retail community pharmacy.
53+D. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall conduct spread pricing in the Commonwealth.
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47-C. This section shall apply with respect to contracts with a PBM entered into, amended, extended, or renewed on or after January 1, 2026.
55+E. Each carrier on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager shall comply with the provisions of this section in addition to complying with the provisions of 38.2-3407.15:1.
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57+F. Any individual or entity that violates the provisions of this section may be subject to a civil penalty of $5,000 for each day on which such violation occurs.
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59+ 38.2-3469. Enforcement; investigative authority; regulations.
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61+A. The Commission shall enforce this article.
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63+B. The Commission shall have the power to examine and investigate the affairs of any person engaged or alleged to be engaged in pharmacy benefits management services in the Commonwealth to determine whether the individual or entity has engaged or is engaging in any violation of this article.
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65+C. Pursuant to the authority granted by 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this article.