Pharmacy Benefits Management

Any individual or entity providing pharmacy benefits management services or otherwise acting as a pharmacy benefits manager in Virginia on or after October 1, 2020, is required to obtain a license unless otherwise covered by a carrier’s license. Beginning April 1, 2022, all license applications must be filed electronically through Sircon using the application link below. 

Apply for a License:

To apply, submit an application for an initial license or renewal license and pay the specified application fee. For an initial license, the fee is $250; to renew a license, the fee is $100. Licenses may be renewed beginning 90 days prior to the October 1 annual effective date.

Initial Licensure:

When completing an application for initial licensure via Sircon, resident applicants must select “New Insurance Licenses” and non-resident applicants must select “Other Licenses.”

License Renewal:

When completing an application for license renewal via, select "Renew Insurance Licenses".

Existing licenses not renewed by October 1, will be processed as an initial license and require payment of the $250 license fee.

View Administrative Letter 2020-04 (Revised 6/27/2023) for further information.

Any carrier which provides health benefit plans and contracts with one or more pharmacy benefits managers to manage pharmacy benefits must file an annual rebate report with the Commissioner of Insurance on or before March 31, for the preceding calendar year. For example, the rebate report for calendar year 2024 is due on or before March 31, 2025. The carrier may submit the report on its own or through its pharmacy benefits manager or managers pursuant to its contract for pharmacy benefits management.

During its 2024 Session, the General Assembly expanded the scope of rebate reporting by requiring additional information. Therefore, the report filed with the Commissioner must, for each health benefit plan, now include:

• the aggregate amount of rebates received by the pharmacy benefits manager;

• the aggregate amount of rebates distributed to the appropriate health benefit plan;

• the aggregate amount of rebates passed on to the enrollees of each health benefit plan at the point of sale that reduced the enrollees' applicable deductible, copayment, coinsurance, or other cost-sharing amount.

• the aggregate amount of the pharmacy benefits manager's retained rebates;

• the pharmacy benefits manager's aggregate retained rebate percentage; and

• the aggregate amount of administrative fees received by the pharmacy benefits manager.

For  purposes of this report, a “rebate” is “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 utilization of a prescription drug and (ii) paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefits manager, pharmacy services administrative organization, or pharmacy after a claim has been processed and paid at a pharmacy.”

IMPORTANT NOTE: This rebate reporting requirement administered by the Bureau of Insurance pursuant to § 38.2-3468, Code of Virginia, should not be confused with a similar prescription drug price transparency reporting requirement being administered by the Virginia Department of Health through a nonprofit data services organization (Virginia Health Information) pursuant to § 32.1-23.4 of the Code, as further set forth in 12VAC5-219. The Bureau's report should be emailed to BOIPBMRebateReports@scc.virginia.gov, whereas the Virginia Department of Health report should be emailed to rxpricing@vhi.org.

The Bureau encourages carriers and pharmacy benefits managers to be aware of prohibited conduct related to advertisements, claims adjudication fees, reimbursements for services, network restrictions or adequacy determinations, retaliation for exercising rights and spread pricing.

See § 38.2-3467, Code of Virginia, for details.

The Bureau of Insurance responds to complaints filed against pharmacy benefits managers (PBM) by insureds, patients, pharmacists and others, on matters within its regulatory authority.

To file a complaint against a PBM providing pharmacy benefits management services for commercial health plans under Virginia law, use the PBM Complaint Form.

Provide as much information as possible. Attach copies of all supporting documentation to the completed complaint form, and keep the original documents for your records. Submit a separate complaint form for each PBM.

Send the completed form to the Bureau of Insurance using one of the following methods:

Email:        BOIPBMComplaints@scc.virginia.gov

Mail:          Pharmacy Benefits Manager Complaints
                  Virginia Bureau of Insurance
                  State Corporation Commission
                  P.O. Box 1157
                  Richmond, VA 23218

Fax:           804-371-9944

Complaints against a PBM servicing a Medicaid plan should be directed to the Department of Medical Assistance Services, and not be filed with the Bureau of Insurance.