Virginia HB 1271: Health insurance; pharmacy benefits managers; requirements and prohibited conduct.

Bill Text

2026 SESSION

INTRODUCED

26101229D

HOUSE BILL NO. 1271

Offered January 14, 2026

Prefiled January 14, 2026

A BILL to amend and reenact §§ 38.2-3465, 38.2-3467, and 38.2-3469 of the Code of Virginia and to amend the Code of Virginia by adding a section numbered 38.2-3467.1, relating to health insurance; pharmacy benefits management; requirements and prohibited conduct; retail pharmacy network access standards; enforcement; civil penalty.

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Patron—Wachsmann

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Referred to Committee on Labor and Commerce

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Be it enacted by the General Assembly of Virginia:

1. That §§ 38.2-3465, 38.2-3467, and 38.2-3469 of the Code of Virginia are amended and reenacted and that the Code of Virginia is amended by adding a section numbered 38.2-3467.1 as follows:

§ 38.2-3465. Definitions.

A. As used in this article, unless the context requires a different meaning:

"Aggregate retained rebate percentage" means the sum total dollar amount of a pharmacy benefits manager's retained rebates relating to all carrier clients of such pharmacy benefits manager divided by the sum total dollar amount of all rebates received by such pharmacy benefits manager relating to all such clients.

"Carrier" has the same meaning ascribed thereto in subsection A of § 38.2-3407.15. However, "carrier" does not include a nonprofit health maintenance organization that operates as a group model whose internal pharmacy operation exclusively serves the members or patients of the nonprofit health maintenance organization.

"Claim" means a request from a pharmacy or pharmacist to be reimbursed for the cost of administering, filling, or refilling a prescription for a drug or for providing a medical supply or device.

"Claims processing services" means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include (i) receiving payments for pharmacist services, (ii) making payments to pharmacists or pharmacies for pharmacist services, or (iii) both receiving and making payments.

"Contract pharmacy" means a pharmacy operating under contract with a 340B-covered entity to provide dispensing services to the 340B-covered entity, as described in 75 Fed. Reg. 10272 (March 5, 2010) or any superseding guidance published thereafter.

"Covered entity" means an entity described in § 340B(a)(4) of the federal Public Health Service Act, 42 U.S.C. § 256B(a)(4).

"Covered individual" means an individual receiving prescription medication coverage or reimbursement provided by a pharmacy benefits manager or a carrier under a health benefit plan.

"Health benefit plan" has the same meaning ascribed thereto in § 38.2-3438.

"Mail order pharmacy" means a pharmacy whose primary business is to receive prescriptions by mail or through electronic submissions and to dispense medication to covered individuals through the use of the United States mail or other common or contract carrier services and that provides any consultation with covered individuals electronically rather than face-to-face.

"Pharmacy benefits management" means the administration or management of prescription drug benefits provided by a carrier for the benefit of covered individuals. "Pharmacy benefits management" does not include any service provided by a nonprofit health maintenance organization that operates as a group model provided that the service is furnished through the internal pharmacy operation exclusively serves the members or patients of the nonprofit health maintenance organization. "Pharmacy benefits management" does not include the activities of an employer managing its own self-funded health benefit plan, except to the extent permitted by applicable law that the employer, without the utilization of a third party and unrelated to the employer's own pharmacy, (i) negotiates directly with drug manufacturers, (ii) processes claims on behalf of its members, or (iii) manages its own retail network of pharmacies. "Pharmacy benefits management" also does not include a pharmacy providing a patient with a discount card or program that is for exclusive use at the pharmacy offering the discount.

"Pharmacy benefits manager" or "PBM" means an entity that performs pharmacy benefits management. "Pharmacy benefits manager" includes an entity acting for a PBM in a contractual relationship in the performance of pharmacy benefits management for a carrier, nonprofit hospital, or third-party payor under a health program administered by the Commonwealth.

"Pharmacy benefits manager affiliate" means a business, pharmacy, or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership interest or control with a pharmacy benefits manager.

"Rebate" means a discount or other price concession, including without limitation incentives, disbursements, and reasonable estimates of a volume-based discount, or a payment that is (i) based on utiliz