Pharmacy audits; pharmacy benefits manager. (HB2561)

Introduced By

Sen. Todd E. Pillion (R-Abingdon) with support from co-patron Del. Israel O'Quinn (R-Bristol)


Passed Committee
Passed House
Passed Senate
Signed by Governor
Became Law


Pharmacy audits; pharmacy benefits managers. Requires that any contract between a carrier and its intermediary pursuant to which the intermediary has the right or obligation to conduct audits of participating pharmacy providers and any provider contract between a carrier and a participating pharmacy provider or its contracting agent pursuant to which the carrier has the right or obligation to conduct audits of participating pharmacy providers contain certain terms and provisions relating to audits that will apply in the absence of fraud. The terms and provisions (i) require at least 14 days' written notice before conducting the initial audit for each audit cycle; (ii) prohibit the initiation or scheduling of an onsite audit during the first five calendar days of any month or on a Monday; (iii) prohibit an onsite audit of a particular pharmacy location on behalf of a particular carrier more than once in a 12-month period; (iv) require each pharmacy to be audited under the same standards and parameters as every other similarly situated pharmacy; (v) require any audit issues that involve clinical or professional judgment to be conducted by a pharmacist who has available for consultation a pharmacist licensed by the Commonwealth; (vi) require each audit to be conducted by a field agent who possesses the requisite knowledge and experience in pharmacy practice; (vii) require audits to be conducted in the Commonwealth in compliance with federal and state laws, rules, and regulations; (viii) require prescriptions to be considered valid prescriptions if they are compliant with the then-current Board of Pharmacy rules and regulations and have been successfully adjudicated upon a clean claim submission; (ix) require electronic records and documentation to be acceptable for auditing under the same terms, conditions, and validation and for the same purposes as their paper analogs; (x) permit a pharmacy to use the historical records of a hospital, physician, or other authorized practitioner of the healing arts for drugs or medicinal supplies written and transmitted by any documented means of communication for purposes of validating the pharmacy record with respect to orders or refills of a legend or narcotic drug; (xi) require validation and documentation at the time of dispensing of appropriate days' supply and drug dosing to be based on manufacturer guidelines and definitions or, in the case of topical products or titrated products, based on the professional judgment of the pharmacist in communication with the patient or prescriber; (xii) require a pharmacy's usual and customary price for compounded medications to be considered the reimbursable cost unless the pricing methodology is published in the provider contract and signed by both parties or their agents; (xiii) prohibit a carrier or its intermediary from making charge backs or seeking recoupment from a pharmacy, or assessing or collecting penalties from a pharmacy, until the time period for filing an appeal to an initial audit report has passed or until the appeals process has been exhausted, whichever is later; (xiv) establish requirements for a preliminary audit report; (xv) require a pharmacy to be allowed at least 60 calendar days following receipt of the preliminary audit report in which to produce documentation to address any discrepancy found during an audit or to file an appeal; (xvi) establish time periods during which a final audit report containing claim level information for any discrepancy found and total dollar amount of claims subject to recovery is required to be delivered to the pharmacy or its pharmacy corporate office; (xvii) prohibit a carrier or its intermediary from recovering from the pharmacy payment of claims that is identified through the audit process to be the responsibility of another payer; (xviii) prohibit recoupment of amounts paid to a pharmacy for any claim to be made solely on the basis of a prescriber's or patient's lack of response to a request made by a carrier or its intermediary; (xix) require a carrier or its intermediary to issue its initial audit findings in conformity with the laws of the Commonwealth; and (xx) prohibit a carrier or its intermediary from retroactively denying a claim in certain circumstances. Read the Bill »


Bill Has Passed


01/09/2019Prefiled and ordered printed; offered 01/09/19 19103158D
01/09/2019Referred to Committee on Health, Welfare and Institutions
01/16/2019Assigned HWI sub: Subcommittee #1
01/23/2019Impact statement from SCC (HB2561)
01/24/2019Referred from Health, Welfare and Institutions
01/24/2019Referred to Committee on Commerce and Labor
01/31/2019House committee, floor amendments and substitutes offered
01/31/2019Reported from Commerce and Labor with substitute (20-Y 0-N) (see vote tally)
01/31/2019Committee substitute printed 19105852D-H1
02/03/2019Read first time
02/04/2019Read second time
02/04/2019Committee substitute agreed to 19105852D-H1
02/04/2019Engrossed by House - committee substitute HB2561H1
02/05/2019Read third time and passed House BLOCK VOTE (99-Y 0-N)
02/05/2019VOTE: BLOCK VOTE PASSAGE (99-Y 0-N) (see vote tally)
02/06/2019Constitutional reading dispensed
02/06/2019Referred to Committee on Education and Health
02/08/2019Assigned Education sub: Health Professions
02/11/2019Impact statement from SCC (HB2561H1)
02/14/2019Reported from Education and Health with amendments (15-Y 0-N) (see vote tally)
02/15/2019Constitutional reading dispensed (37-Y 0-N) (see vote tally)
02/18/2019Read third time
02/18/2019Reading of amendments waived
02/18/2019Committee amendments agreed to
02/18/2019Engrossed by Senate as amended
02/18/2019Passed Senate with amendments (40-Y 0-N) (see vote tally)
02/19/2019Placed on Calendar
02/19/2019Senate amendments agreed to by House (98-Y 0-N)
02/19/2019VOTE: ADOPTION (98-Y 0-N) (see vote tally)
02/22/2019Bill text as passed House and Senate (HB2561ER)
02/22/2019Signed by Speaker
02/22/2019Signed by President
02/25/2019Impact statement from SCC (HB2561ER)
03/04/2019Enrolled Bill communicated to Governor on March 4, 2019
03/04/2019G Governor's Action Deadline Midnight, March 26, 2019
03/21/2019G Approved by Governor-Chapter 665 (effective 7/1/19)
03/21/2019G Acts of Assembly Chapter text (CHAP0665)