Bill > SB875

This bill requires the Department of Medical Assistance Services (DMAS) to select and contract with a single third-party administrator to serve as the state pharmacy benefits manager (PBM) for all Medicaid recipients by July 1, 2026. The bill mandates that the state PBM must administer pharmacy benefits for all Medicaid recipients, including those enrolled in managed care organizations, and imposes several specific requirements on the contract. These requirements include establishing a fiduciary duty to DMAS, using pass-through pricing, adopting the department's common formulary and reimbursement methodologies, ensuring transparency in drug costs and fees, and prohibiting spread pricing (a practice where the PBM charges a health plan more for prescription drugs than it pays pharmacies). Additionally, the bill requires DMAS to engage an independent consultant with experience in Medicaid pharmacy benefits management to evaluate the implementation of the new PBM contract. The consultant must have expertise in advising Medicaid fraud control units and working with states that have established a single PBM for their Medicaid programs, and cannot be affiliated with any Virginia Medicaid managed care organizations or their current PBMs.

Budget and Finance, Health and Social Services

https://lis.virginia.gov/bill-details/20251/SB875