An Act to amend and reenact §§ 38.2-3467 and 38.2-3470 of the Code of Virginia, relating to pharmacy benefits managers; requirements; application of law; report.
HB830 amends Virginia’s insurance code provisions governing pharmacy benefits managers (PBMs) and carriers. The bill expands and clarifies a broad set of prohibited practices, including misleading advertising, certain claim-processing fees, paying pharmacies less than PBM affiliates for the same services, retaliation against pharmacies, discriminatory treatment of 340B covered entities and contract pharmacies, improper claim reversals and retroactive denials, and interference with a patient’s choice of pharmacy. It also bars carriers and PBMs from restricting network participation based on accreditation or certification standards when a pharmacist meets those standards.
The bill further prohibits spread pricing in Virginia and requires carriers and their PBMs to use a pass-through pricing model. If requested by a plan sponsor, the carrier must offer at least one contract structure that limits PBM income to fees for services, with those fees stated in the agreement. The text also excludes mail-order pharmacies and PBM affiliates from being counted in network adequacy calculations under Virginia law or contract, and it includes a limited exception for certain very high-cost drugs in the 340B provisions.
HB830 changes §§ 38.2-3467 and 38.2-3470 of the Code of Virginia, strengthening state regulation of PBM practices and carrier-PBM contracting. Its practical effect is to impose more transparent reimbursement and pricing rules, restrict spread pricing and retroactive claim adjustments, and provide additional protections for independent pharmacies, 340B entities, and covered individuals choosing a pharmacy. It also affects how network adequacy is measured and how PBM compensation arrangements must be structured and disclosed.
The available record shows no committee transcript or recorded vote debate, so there is no detailed public discussion to gauge sentiment. The bill’s enactment as Chapter 678 indicates it ultimately received enough support to pass and be signed into law, suggesting at least majority legislative approval. Based on the substance, the measure appears aligned with concerns about PBM transparency, pharmacy reimbursement fairness, and patient access.
The main likely points of contention are the bill’s restrictions on PBM business practices, especially the ban on spread pricing, limits on retroactive denials and claim reversals, and the requirement to use pass-through pricing. PBMs and carriers would likely view these provisions as constraining contracting flexibility and revenue models, while pharmacies, 340B providers, and patient advocates would likely support them as protections against unfair reimbursement and network practices. The 340B-related nondiscrimination rules and the exclusion of mail-order pharmacies and PBM affiliates from network adequacy calculations are also likely to be debated because they affect market competition and network design.