West Virginia to PBMs: Follow the law or lose your license

NCPA September 17, 2021

The West Virginia Offices of the Insurance Commissioner released a bulletin putting PBMs and health benefits plans on notice about recent changes to the state’s pharmacy provider network adequacy requirements. West Virginia’s freedom of consumer choice law prohibits a PBM from requiring a patient to use a mail order pharmacy. It has come to OIC’s attention that some plans/PBMs have created sub-networks for specialty drugs that consist only of mail order pharmacies. In the bulletin, OIC makes clear that these mail order only sub-networks deprive patients of the freedom to choose pharmacy providers in violation of the law. There are no exceptions to the law, and even those PBMs serving ERISA plans are subject to its provisions. The consequences for continuing these mail order only sub-networks are severe, as OIC is legally prohibited “from approving the licensure of any PBM or approving any health benefit plan that does not conform to the freedom of consumer choice for pharmacy provisions.”