A. Unless otherwise covered by a license as a carrier, no person shall provide pharmacy benefits management services or otherwise act as a pharmacy benefits manager in the Commonwealth without first obtaining a license in a manner and in a form prescribed by the Commission.
B. Each applicant for a license as a pharmacy benefits manager shall make application to the Commission, in the form and containing the information listed in subsection C and any other information the Commission prescribes. The Commission may require any documents reasonably necessary to verify the information contained in an application. Each applicant shall, at the time of applying for a license, pay a nonrefundable application processing fee in an amount and in a manner prescribed by the Commission. The fee shall be collected by the Commission and paid directly into the state treasury and credited to the "Bureau of Insurance Special Fund — State Corporation Commission" for the maintenance of the Bureau of Insurance as provided in subsection B of § 38.2-400.
C. An applicant for a license as a pharmacy benefits manager shall provide the Commission the following information:
1. The name, address, and telephone contact number of the pharmacy benefits manager;
2. The name and address of each person with management or control over the pharmacy benefits manager;
3. The name and address of each person with a beneficial ownership interest in the pharmacy benefits manager; and
4. If the pharmacy benefits manager registrant (i) is a partnership or other unincorporated association, a limited liability company, or a corporation and (ii) has five or more partners, members, or stockholders, the registrant shall specify its legal structure and the total number of its partners, members, or stockholders who, directly or indirectly, own, control, hold with the power to vote, or hold proxies representing 10 percent or more of the voting securities of any other person.
D. An applicant shall provide the Commissioner with a signed statement indicating that, to the best of its knowledge, no officer with management or control of the pharmacy benefits manager has been convicted of a felony or has violated any of the requirements of state law applicable to pharmacy benefits managers, or, if the applicant cannot provide such a statement, a signed statement describing the relevant conviction or violation.
E. Except where prohibited by state or federal law, by submitting an application for a license, the applicant shall be deemed to have appointed the clerk of the Commission as the agent for service of process on the applicant in any action or proceeding arising in the Commonwealth out of or in connection with the exercise of the license. Such appointment of the clerk of the Commission as agent for service of process shall be irrevocable during the period within which a cause of action against the applicant may arise out of transactions with respect to subjects of pharmacy benefits management in the Commonwealth. Service of process on the clerk of the Commission shall conform to the provisions of Chapter 8 (§ 38.2-800 et seq.).
F. Each applicant that has complied with the provisions of this article and Commission regulations is entitled to and shall receive a license in the form the Commission prescribes.
G. Each pharmacy benefits manager shall renew its license annually and shall, at the time of renewal, pay a renewal fee in an amount and in a manner prescribed by the Commission. The fee shall be collected by the Commission and paid directly into the state treasury and credited to the "Bureau of Insurance Special Fund — State Corporation Commission" for the maintenance of the Bureau of Insurance as provided in subsection B of § 38.2-400.
H. The Commission may refuse to issue or renew a license or may revoke or suspend a license if it finds that the applicant or license holder has not complied with the provisions of this article or Commission regulations.
2020, cc. 219, 1288.
Structure Code of Virginia
Chapter 34 - Provisions Relating to Accident and Sickness Insurance
§ 38.2-3400. Application of chapter
§ 38.2-3401. Forms of insurance authorized
§ 38.2-3402. Certification to accompany application
§ 38.2-3403. Fraudulent procurement of policy
§ 38.2-3405.1. Commonwealth's right to certain accident and sickness benefits
§ 38.2-3406. Accident and sickness benefits not subject to legal process
§ 38.2-3406.2. Capped benefits under insurance policies and contracts
§ 38.2-3407. Health benefit programs
§ 38.2-3407.1. Interest on accident and sickness claim proceeds
§ 38.2-3407.2. Coverage for medical child support
§ 38.2-3407.3. Calculation of cost-sharing provisions
§ 38.2-3407.3:1. Premium payment arrearages; order of crediting payments
§ 38.2-3407.4. Explanation of benefits
§ 38.2-3407.4:2. Requirements for prescription benefit cards
§ 38.2-3407.5. Denial of benefits for certain prescription drugs prohibited
§ 38.2-3407.5:1. Coverage for prescription contraceptives
§ 38.2-3407.5:2. Reimbursements for dispensing hormonal contraceptives
§ 38.2-3407.6. Exclusion of podiatrist not permitted under certain circumstances
§ 38.2-3407.6:1. Denial of benefits for certain prescription drugs prohibited
§ 38.2-3407.7. Pharmacies; freedom of choice
§ 38.2-3407.9. Reimbursement for emergency medical services vehicle transportation services
§ 38.2-3407.9:01. Prescription drug formularies
§ 38.2-3407.9:02. Requirement for prescription drug coverage
§ 38.2-3407.9:03. Payment of clean claims to administrators of pharmacy benefits
§ 38.2-3407.9:04. Medication synchronization
§ 38.2-3407.9:05. Step therapy protocols
§ 38.2-3407.10. Health care provider panels
§ 38.2-3407.10:2. Credentialing of private mental health agencies
§ 38.2-3407.11. Access to obstetrician-gynecologists
§ 38.2-3407.11:1. Access to specialists; standing referrals
§ 38.2-3407.11:2. Standing referral for cancer patients
§ 38.2-3407.11:3. Breast cancer underwriting and preexisting condition restrictions
§ 38.2-3407.11:4. Disability arising out of childbirth; minimum benefit
§ 38.2-3407.11:5. Interhospital transfer for newborn or mother; prior authorization prohibited
§ 38.2-3407.12. Patient optional point-of-service benefit
§ 38.2-3407.13. Refusal to accept assignments prohibited; dentists and oral surgeons
§ 38.2-3407.13:1. Coordination of benefits; notice of priority of coverage
§ 38.2-3407.13:2. Claims paid to insureds for services from nonparticipating physicians
§ 38.2-3407.14. Notice of premium or deductible increases
§ 38.2-3407.15. Ethics and fairness in carrier business practices
§ 38.2-3407.15:2. Carrier contracts; required provisions regarding prior authorization
§ 38.2-3407.15:4. Limit on copayment for prescription drugs; permitted disclosures
§ 38.2-3407.15:5. Limit on cost-sharing payments for prescription insulin drugs
§ 38.2-3407.15:6. Prescription drug price transparency
§ 38.2-3407.16. Requirements for obstetrical care
§ 38.2-3407.17. Payment for services by dentists and oral surgeons
§ 38.2-3407.17:1. Payment and reimbursement practices for dental services; network access
§ 38.2-3407.18. Requirements for orally administered cancer chemotherapy drugs
§ 38.2-3407.19. Payment for services by optometrists and ophthalmologists
§ 38.2-3407.21. Short-term limited-duration medical plans
§ 38.2-3407.22. Option for rebates to enrollees; protected information
§ 38.2-3409. Coverage of dependent children
§ 38.2-3410. Construction of policy generally; words "physician" and "doctor" to include dentist
§ 38.2-3411. Coverage of newborn children required
§ 38.2-3411.1. Coverage for child health supervision services
§ 38.2-3411.2. Coverage of adopted children required
§ 38.2-3411.3. Coverage for childhood immunizations
§ 38.2-3411.4. Coverage for infant hearing screening and related diagnostics
§ 38.2-3412.1. Coverage for mental health and substance use disorders
§ 38.2-3414. Optional coverage for obstetrical services
§ 38.2-3414.1. Obstetrical benefits; coverage for postpartum services
§ 38.2-3415. Exclusion or reduction of benefits for certain causes prohibited
§ 38.2-3417. Deductibles and coinsurance options required
§ 38.2-3418. Coverage for victims of rape or incest
§ 38.2-3418.1. Coverage for mammograms
§ 38.2-3418.1:2. Coverage for pap smears
§ 38.2-3418.2. Coverage of procedures involving bones and joints
§ 38.2-3418.3. Coverage for hemophilia and congenital bleeding disorders
§ 38.2-3418.4. Coverage for reconstructive breast surgery; notice; eligibility
§ 38.2-3418.5. Coverage for early intervention services
§ 38.2-3418.6. Minimum hospital stay for mastectomy and certain lymph node dissection patients
§ 38.2-3418.7. Coverage for PSA testing
§ 38.2-3418.7:1. Coverage for colorectal cancer screening
§ 38.2-3418.8. Coverage for clinical trials for treatment studies on cancer
§ 38.2-3418.9. Minimum hospital stay for hysterectomy
§ 38.2-3418.10. Coverage for diabetes
§ 38.2-3418.11. Coverage for hospice care
§ 38.2-3418.12. Coverage for hospitalization and anesthesia for dental procedures
§ 38.2-3418.13. Coverage for the treatment of morbid obesity
§ 38.2-3418.14. Coverage for lymphedema
§ 38.2-3418.15. Coverage for prosthetic devices and components
§ 38.2-3418.15:1. Coverage for prosthetic devices and components
§ 38.2-3418.16. Coverage for telemedicine services
§ 38.2-3418.17. Coverage for autism spectrum disorder
§ 38.2-3418.18. Coverage for formula and enteral nutrition products as medicine
§ 38.2-3418.19. Coverage for organ, eye or tissue transplant
§ 38.2-3418.20. Coverage for hearing aids and related services
§ 38.2-3419. Additional mandated coverage made optional to group policy or contract holder
§ 38.2-3419.1. Report of costs and utilization of mandated benefits
§ 38.2-3420. Authority and jurisdiction of Commission; exception
§ 38.2-3421. How to show jurisdiction of other state agency or federal government
§ 38.2-3423. When subject to this title
§ 38.2-3424. Disclosure of extent and elements of coverage
§ 38.2-3430.1. Application of article
§ 38.2-3430.1:1. Health insurance coverage not required
§ 38.2-3430.4. Special rules for network plans
§ 38.2-3430.5. Application of financial capacity limits
§ 38.2-3430.6. Market requirements
§ 38.2-3430.7. Renewability of individual health insurance coverage
§ 38.2-3430.8. Certification of coverage
§ 38.2-3430.9. Regulations establishing standards
§ 38.2-3430.10. Effective date
§ 38.2-3431. Application of article; definitions
§ 38.2-3432.3. Limitation on preexisting condition exclusion period
§ 38.2-3434. Disclosure of information
§ 38.2-3436. Eligibility to enroll
§ 38.2-3437. Rules used to determine group size
§ 38.2-3439. Dependent coverage for individuals to age 26
§ 38.2-3440. Lifetime and annual limits
§ 38.2-3442. Preventive services
§ 38.2-3443. Choice of a health care professional
§ 38.2-3444. Preexisting condition exclusions
§ 38.2-3445. Patient access to emergency services
§ 38.2-3445.01. Balance billing for certain services; prohibited
§ 38.2-3445.03. Data sets for determining commercially reasonable payments
§ 38.2-3445.06. Applicability of certain sections
§ 38.2-3445.07. Rules and regulations
§ 38.2-3445.2. Out-of-network claims; reporting requirements
§ 38.2-3446. Applicability of federal law
§ 38.2-3447. Restrictions relating to premium rates
§ 38.2-3448. Guaranteed availability
§ 38.2-3449. Prohibiting discrimination based on health status
§ 38.2-3450. Genetic information and testing
§ 38.2-3451. Essential health benefits
§ 38.2-3454. Wellness programs
§ 38.2-3454.1. Renewal of health benefit plans; special exception
§ 38.2-3456. Prohibited activities
§ 38.2-3457. Application for registration
§ 38.2-3458. Power of Commission to investigate navigators
§ 38.2-3462. Comparable Health Care Service Incentive Program
§ 38.2-3463. Health care price transparency tools
§ 38.2-3464. Rules and regulations; orders
§ 38.2-3467. Prohibited conduct by carriers and pharmacy benefits managers
§ 38.2-3468. Examination of books and records; reports; access to records
§ 38.2-3469. (Effective October 1, 2020) Enforcement; regulations