2006 Code of Virginia § 38.2-4312.1 - Pharmacies; freedom of choice

38.2-4312.1. Pharmacies; freedom of choice.

A. Notwithstanding any other provision in this chapter, no health maintenanceorganization providing health care plans shall prohibit any person receivingpharmaceutical benefits thereunder from selecting, without limitation, thepharmacy of his choice to furnish such benefits. This right of selectionextends to and includes pharmacies that are not participating providers underany such health care plan and that have previously notified the healthmaintenance organization, by facsimile or otherwise, of their agreement toaccept reimbursement for their services at rates applicable to pharmaciesthat are participating providers, including any copayment consistentlyimposed by the plan, as payment in full. Each health maintenance organizationshall permit prompt electronic or telephonic transmittal of the reimbursementagreement by the pharmacy and ensure prompt verification to the pharmacy ofthe terms of reimbursement. In no event shall any person receiving a coveredpharmacy benefit from a nonparticipating provider which has submitted areimbursement agreement be responsible for amounts that may be charged by thenonparticipating provider in excess of the copayment and the healthmaintenance organization's reimbursement applicable to all of itsparticipating pharmacy providers.

B. No such health maintenance organization shall impose upon any personreceiving pharmaceutical benefits furnished under any such health care plan:

1. Any copayment, fee or condition that is not equally imposed upon allindividuals in the same benefit category, class or copayment level, whetheror not such benefits are furnished by pharmacists who are not participatingproviders;

2. Any monetary penalty that would affect or influence any such person'schoice of pharmacy; or

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

C. For purposes of this section, a prohibited condition or penalty shallinclude, without limitation: (i) denying immediate access to electronicclaims filing to a pharmacy which is a nonparticipating provider and whichhas complied with subsection E below or (ii) requiring a person receivingpharmacy benefits to make payment at point of service, except to the extentsuch conditions and penalties are similarly imposed on participatingproviders.

D. The provisions of this section are not applicable to any pharmaceuticalbenefit covered by a health care plan when those benefits are obtained from apharmacy wholly owned and operated by, or exclusively operated for, thehealth maintenance organization providing the health care plan.

E. Any pharmacy which wishes to be covered by this section shall, ifrequested to do so in writing by a health maintenance organization, withinthirty days of the pharmacy's receipt of the request, execute and deliver tothe health maintenance organization the direct service agreement orparticipating provider agreement which the health maintenance organizationrequires all of its participating providers of pharmacy benefits to execute.Any pharmacy which fails to timely execute and deliver such agreement shallnot be covered by this section with respect to that health maintenanceorganization unless and until the pharmacy executes and delivers theagreement.

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

(1994, c. 963; 1995, cc. 446, 467.)