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Virginia PBM MAC rights
Statute Va. Code § 38.2-3407.15:3
Partly unverified. At least one field below could not be confirmed against primary text. Those fields say so. We would rather show the gap than fill it.
Whether the statute gives a pharmacy a right to see the list of drugs priced off maximum allowable cost.
Some states require it to be electronic and searchable. Most say nothing, which in practice means a PDF.
A demonstrably staler list is itself a violation in most states.
Read the trigger carefully. A clock running from adjudication is much shorter in practice than one running from payment.
The strongest provision in this area. A named drug code, and better a named wholesaler, is a claim you can check against your own catalogue.
In a few states a successful appeal corrects the price for every similarly situated pharmacy, sometimes retroactively.
The weakest column in our data. Several are marked unverified rather than guessed at.
Work out your actual deadline
Virginia gives you 14 days. The date that clock starts from is the part people get wrong, and it is usually earlier than they assume. Put your claim date in and get the calendar date back.
Before you rely on a deadline, know which plan is behind the claim
State MAC rights are strongest on commercial claims — individual plans, fully insured employer plans, and in many states the state employee plan. For self-funded employer plans they stand, because the Supreme Court's 2020 Rutledge decision specifically upheld MAC update and appeal mandates.
Medicare Part D is the real problem. Federal law expressly supersedes state regulation of Part D plans, two federal circuits apply that rule at very different levels of generality, and in Arkansas a federal court entered final judgment that the state MAC law is preempted as to Part D. Part D is roughly a quarter of a typical independent's volume, so this is not a footnote.
Medicaid depends entirely on your own state's statute — some exempt it by name, some cover it by name, most are silent. TRICARE and federal-employee claims should be treated as outside these rights.
What to do with this
- Check your own contract first. In most states it has to name the pricing sources the PBM uses. That is a document you already have.
- Ask for the list. There is a free template here. No state publishes one, so we wrote it.
- Send it to the right place. Sixty-odd licensed PBMs collapse to about eight actual appeal endpoints. Here is where each one goes.
- Tell us what happened. Nobody publishes whether these duties are actually honoured. Two minutes, and it becomes public data.
Sources
- code.wvlegislature.gov — 33-51-9
- apps.sos.wv.gov — rule
- wvlegislature.gov — bills_history.cfm
- scc.virginia.gov — pharmacy-benefits-mgmt
- wvinsurance.gov — PBM Complaint Form
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