Prescription Drug Coverage

V.S.A. tit. 8, ch. 107, subch. 10

in effect

8 V.S.A. § 4091 Definitions

4091. Definitions As used in this subchapter: (1) “Direct solicitation” means direct contact, including telephone, computer, email, instant messaging, or in-person contact, by a pharmacy provider or its agent to an individual covered under a health insurance plan without the covered individual’s consent for the purpose of marketing the pharmacy provider’s services. (2) “Health care professional” means an individual licensed to practice medicine under 26 V.S.A. chapter 23 or 33, an individual licensed as a physician assistant under 26 V.S.A. chapter 31, or an individual licensed as an advanced practice registered nurse under 26 V.S.A. chapter 28. (3) “Health insurance plan” has the same meaning as in section 4011 of this chapter and includes prescription drug benefits managed by a health insurer or by a pharmacy benefit manager on behalf of a health insurer. (4) “Interchangeable biological products” has the same meaning as in 18 V.S.A. § 4601. (5) “Out-of-pocket expenditure” means a co-payment, coinsurance, deductible, or other cost-sharing mechanism. (6) “Pharmacy benefit manager” means an entity that performs pharmacy benefit management. “Pharmacy benefit management” means an arrangement for the procurement of prescription drugs at negotiated dispensing rates, the administration or management of prescription drug benefits provided by a health insurance plan for the benefit of beneficiaries, or any of the following services provided with regard to the administration of pharmacy benefits: (A) mail service pharmacy; (B) claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries; (C) clinical formulary development and management services; (D) rebate contracting and administration; (E) certain patient compliance, therapeutic intervention, and generic substitution programs; and (F) disease management programs. (7) “Pharmacy benefit manager affiliate” means a pharmacy or pharmacist that, directly or indirectly, through one or more intermediaries, is owned or controlled by, or is under common ownership or control with, a pharmacy benefit manager. (8) “Prescription drug” or “drug” has the same meaning as “prescription drug” in 26 V.S.A. § 2022 and includes: (A) biological products, as defined in 18 V.S.A. § 4601; (B) medications used to treat complex, chronic conditions, including medications that require administration, infusion, or injection by a health care professional; (C) medications for which the manufacturer or the U.S. Food and Drug Administration requires exclusive, restricted, or limited distribution; and (D) medications with specialized handling, storage, or inventory reporting requirements. (9) “Prescription insulin medication” means a prescription drug that contains insulin and is used to treat diabetes. (10) “Step therapy” means protocols that establish the specific sequence in which prescription drugs for a specific medical condition are to be prescribed. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4092 Prescription drug coverage

4092. Prescription drug coverage (a) A health insurance plan shall not include an annual dollar limit on prescription drug benefits. (b) A health insurance plan shall limit a covered individual’s out-of-pocket expenditures for all prescription drugs to not more for self-only and family coverage per year than the minimum dollar amounts in effect under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively. (c)(1) For prescription drug benefits offered in conjunction with a high-deductible health plan (HDHP), the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the HDHP have met the amount of the minimum annual deductibles in effect for self-only and family coverage under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, except that a plan may offer first-dollar prescription drug benefits to the extent permitted under federal law. (2) Once the applicable expenditure amount set forth in subdivision (1) of this subsection has been met under the HDHP, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in subsection (b) of this section. (d)(1) A health insurance plan that uses step-therapy protocols shall: (A) not require failure, including discontinuation due to lack of efficacy or effectiveness, diminished effect, or an adverse event, on the same drug on more than one occasion for covered individuals who are continuously enrolled in a plan offered by the health insurer or its pharmacy benefit manager; and (B) grant an exception to its step-therapy protocols upon request of a covered individual or the covered individual’s treating health care professional under the same time parameters as set forth for prior authorization requests in 18 V.S.A. § 9418b(g)(4) if any one or more of the following conditions apply: (i) the prescription drug required under the step-therapy protocol is contraindicated or will likely cause an adverse reaction or physical or mental harm to the covered individual; (ii) the prescription drug required under the step-therapy protocol is expected to be ineffective based on the covered individual’s known clinical history, condition, and prescription drug regimen; (iii) the covered individual has already tried the prescription drugs on the protocol, or other prescription drugs in the same pharmacologic class or with the same mechanism of action, which have been discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event, regardless of whether the covered individual was covered at the time on a plan offered by the current insurer or its pharmacy benefit manager; (iv) the covered individual is stable on a prescription drug selected by the covered individual’s treating health care professional for the medical condition under consideration; or (v) the step-therapy protocol or a prescription drug required under the protocol is not in the covered individual’s best interests because it will: (I) pose a barrier to adherence; (II) likely worsen a comorbid condition; or (III) likely decrease the covered individual’s ability to achieve or maintain reasonable functional ability. (2) Nothing in this subsection shall be construed to prohibit the use of tiered co-payments for covered individuals not subject to a step-therapy protocol. (3) Notwithstanding any provision of subdivision (1) of this subsection to the contrary, a health insurance shall not utilize a step-therapy, “fail first,” or other protocol that requires documented trials of a prescription drug, including a trial documented through a “MedWatch” (FDA Form 3500), before approving a prescription for the treatment of substance use disorder. (e)(1) A health insurance plan shall not require, as a condition of coverage, use of drugs not indicated by the U.S. Food and Drug Administration for the condition diagnosed and being treated under the supervision of a health care professional. (2) Nothing in this subsection shall be construed to prevent a health care professional from prescribing a prescription drug for off-label use. (f) A health insurance plan shall apply the same cost-sharing requirements to interchangeable biological products as apply to generic drugs under the plan. (g)(1) A health insurance plan shall limit a covered individual’s total out-of-pocket responsibility for prescription insulin drugs to not more than $100.00 per 30-day supply, regardless of the amount, type, or number of insulin drugs prescribed for the covered individual. (2) The $100.00 monthly limit on out-of-pocket spending for prescription insulin drugs set forth in subdivision (1) of this subsection shall apply regardless of whether the covered individual has satisfied any applicable deductible requirement under the health insurance plan. (h) A health insurance plan shall cover, without requiring prior authorization, at least one readily available asthma controller drug from each class of drug and mode of administration. As used in this subsection, “readily available” means that the medication is not listed on a national drug shortage list, including lists maintained by the U.S. Food and Drug Administration and by the American Society of Health-System Pharmacists. (i)(1) On a periodic basis but not less than once per calendar year, each health insurer shall notify all individuals covered under its health insurance plans of any changes in pharmaceutical coverage and provide access to the preferred drug list maintained by the health insurer or its pharmacy benefit manager. (2) Not less than 60 days prior to removing a prescription drug from its formulary or from the formulary maintained by a pharmacy benefit manager on its behalf, a health insurer shall notify all individuals covered under its health insurance plans who filled a prescription for that prescription drug within the previous 12-month period that coverage for the drug will be discontinued and of the date on which the coverage will end. (j) The Department of Financial Regulation shall enforce this section and may adopt rules as necessary to carry out the purposes of this section. (k) A health insurance plan shall provide coverage for prescription drugs purchased in Canada and used in Canada or reimported legally on the same benefit terms and conditions as prescription drugs purchased in this country. For drugs purchased by mail or through the internet, the plan may require accreditation by the Internet and Mailorder Pharmacy Accreditation Commission (IMPAC™) or similar organization. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025; amended 2025, No. 173 (Adj. Sess.), § 9, eff. June 18, 2026.

8 V.S.A. § 4093 Retail pharmacies; filling of prescriptions

4093. Retail pharmacies; filling of prescriptions (a) A health insurer or pharmacy benefit manager doing business in Vermont shall permit a retail pharmacist licensed under 26 V.S.A. chapter 36 to fill prescriptions for all prescription drugs in the same manner and at the same level of reimbursement as they are filled by any other pharmacist or pharmacy, including a mail-order pharmacy or a pharmacy benefit manager affiliate, with respect to the quantity of drugs or days’ supply of drugs dispensed under each prescription. (b) Notwithstanding any provision of a health insurance plan to the contrary, if a health insurance plan provides for payment or reimbursement that is within the lawful scope of practice of a pharmacist, the health insurer may provide payment or reimbursement for the service when the service is provided by a pharmacist. (c)(1) A health insurer or pharmacy benefit manager shall permit a participating network pharmacy to perform all pharmacy services within the lawful scope of the profession of pharmacy as set forth in 26 V.S.A. chapter 36. (2) A health insurer or pharmacy benefit manager shall not do any of the following: (A) Require a covered individual, as a condition of payment or reimbursement, to purchase pharmacist services, including prescription drugs, exclusively through a mail-order pharmacy or a pharmacy benefit manager affiliate. (B) Offer or implement plan designs that require a covered individual to use a mail-order pharmacy or a pharmacy benefit manager affiliate. (C) Order a covered individual, orally or in writing, including through online messaging, to use a mail-order pharmacy or a pharmacy benefit manager affiliate. (D) Establish network requirements that are more restrictive than or inconsistent with State or federal law, rules adopted by the Board of Pharmacy, or guidance provided by the Board of Pharmacy or by drug manufacturers that operate to limit or prohibit a pharmacy or pharmacist from dispensing or prescribing drugs. (E) Offer or implement plan designs that increase plan or patient costs if the covered individual chooses not to use a mail-order pharmacy or a pharmacy benefit manager affiliate. The prohibition in this subdivision (E) includes requiring a covered individual to pay the full cost for a prescription drug when the covered individual chooses not to use a mail-order pharmacy or a pharmacy benefit manager affiliate. (F)(i) Exclude any amount paid by or on behalf of a covered individual, including any third-party payment, financial assistance, discount, discount card, coupon, or other reduction, regardless of whether the individual purchased the drug with or without using coverage for the drug under any health insurance plan, when calculating a covered individual’s contribution toward: (I) the out-of-pocket limits for prescription drug costs under section 4092 of this title; (II) the covered individual’s deductible, if any; or (III) to the extent not inconsistent with Sec. 2707 of the Public Health Service Act, 42 U.S.C. § 300gg-6, the annual out-of-pocket maximums applicable to the covered individual’s health benefit plan. (ii) The provisions of subdivision (i) of this subdivision (F) relating to a third-party payment, financial assistance, discount, coupon, or other reduction in out-of-pocket expenses made on behalf of a covered individual shall only apply to a prescription drug: (I) for which there is no generic drug or interchangeable biological product, as those terms are defined in 18 V.S.A. § 4601; or (II) for which there is a generic drug or interchangeable biological product, as those terms are defined in 18 V.S.A. § 4601, but for which the covered individual has obtained access through prior authorization, a step-therapy protocol, or the pharmacy benefit manager’s or health insurer’s exceptions and appeals process. (iii) The provisions of subdivision (i) of this subdivision (F) shall apply to a high-deductible health plan only to the extent that it would not disqualify the plan from eligibility for a health savings account pursuant to 26 U.S.C. § 223. (iv) In order to facilitate the appropriate attribution of amounts paid by or on behalf of a covered individual pursuant to subdivision (i) of this subdivision (F) for a covered individual who purchases a prescription drug without using the prescription drug coverage available for the drug under the covered individual’s health insurance plan, the health insurer or pharmacy benefit manager, or both, shall: (I) make readily available on its website a downloadable proof of payment form for a covered individual to use to submit proof of the actual amount that the covered individual paid for the drug; and (II) provide notice to all covered individuals at least annually that they are responsible for providing proof of payment using the downloadable proof of payment form or another mechanism, if the health insurer or pharmacy benefit manager elects to make another mechanism available for submitting proof of payment in addition to the downloadable form, in order to have their spending properly attributed to their out-of-pocket limits, deductible, and out-of-pocket maximums as set forth in subdivision (i) of this subdivision (F). (3) A health insurer or pharmacy benefit manager shall not, by contract, written policy, or written procedure, require that a pharmacy designated by the health insurer or pharmacy benefit manager dispense a medication directly to a covered individual with the expectation or intention that the covered individual will transport the medication to a health care setting for administration by a health care professional. (4) A health insurer or pharmacy benefit manager shall not, by contract, written policy, or written procedure, require that a pharmacy designated by the health insurer or pharmacy benefit manager dispense a medication directly to a health care setting for a health care professional to administer to a covered individual. (5) A health insurer or pharmacy benefit manager shall adhere to the definitions of prescription drugs and the requirements and guidance regarding the pharmacy profession established by State and federal law and the Vermont Board of Pharmacy and shall not establish classifications of or distinctions between prescription drugs, impose penalties on prescription drug claims, attempt to dictate the behavior of pharmacies or pharmacists, or place restrictions on pharmacies or pharmacists that are more restrictive than or inconsistent with State or federal law or with rules adopted or guidance provided by the Board of Pharmacy. (6) A pharmacy benefit manager or licensed pharmacy shall not make a direct solicitation to an individual covered by a health insurance plan unless one or more of the following applies: (A) the covered individual has given written permission to the supplier or the ordering health care professional to contact the covered individual regarding the furnishing of a prescription item that is to be rented or purchased; (B) the supplier has furnished a prescription item to the covered individual and is contacting the covered individual to coordinate delivery of the item; or (C) if the contact relates to the furnishing of a prescription item other than a prescription item already furnished to the covered individual, the supplier has furnished at least one prescription item to the covered individual within the 15-month period preceding the date on which the supplier attempts to make the contact. (d) A health insurer or pharmacy benefit manager shall not alter a covered individual’s prescription drug order or the pharmacy chosen by the covered individual without the covered individual’s consent; provided, however, that nothing in this subsection shall be construed to affect the duty of a pharmacist to substitute a lower-cost drug or biological product in accordance with the provisions of 18 V.S.A. § 4605. (e) All of the provisions of this section except subsection (c) shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025; amended 2025, No. 132 (Adj. Sess.), § 2, eff. July 1, 2026.

Source: Vermont General Assembly (legislature.vermont.gov)URL: https://legislature.vermont.gov/statutes/chapter/08/107Fetched: 10/21/2026