loading…
loading…
loading…
As used in this chapter:
(1) "Aggregate retained rebate percentage" means the percentage of all rebates received
from a manufacturer or other entity to a pharmacy benefit manager for prescription drug utilization
which is not passed on to the pharmacy benefit manager’s health carrier clients. The percentage
shall be calculated for each health carrier for rebates in the prior calendar years as follows:
(i) The sum total dollar amount of rebates received from all pharmaceutical manufacturers
for all utilization of covered persons of a health carrier that was not passed through to the health
carrier;
(ii) Divided by the sum total dollar amount of all rebates received from all pharmaceutical
manufacturers for covered persons of a health carrier.
(2) "Health benefit plan" means a policy, contract, certificate or agreement offered or
issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of
healthcare services.
(3) "Health carrier" means an entity subject to the insurance laws and regulations of this
state, or subject to the jurisdiction of the health insurance commissioner, that contracts or offers to
contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of
the cost of healthcare services, including a health insurance company, a health maintenance
organization, a hospital and health services corporation, or any other entity providing a plan of
health insurance, health benefits or healthcare services.
(4) "Pharmacy benefit manager" means a person, business, or other entity that, pursuant to
a contract or under an employment relationship with a health carrier, a self-insurance plan, or other
third-party payer, either directly or through an intermediary, manages the prescription drug
coverage provided by the health carrier, self-insurance plan, or other third-party payer including,
but not limited to, the processing and payment of claims for prescription drugs, the performance of
drug utilization review, the processing of drug prior authorization requests, the adjudication of
appeals or grievances related to prescription drug coverage contracting with network pharmacies,
and controlling the cost of covered prescription drugs.
(5) "Rebates" means all price concessions paid by a manufacturer to a pharmacy benefit
manager or health carrier, including rebates, discounts, and other price concessions that are based
on actual or estimated utilization of a prescription drug. Rebates also include price concessions
based on the effectiveness of a drug as in a value-based or performance-based contract.
(6) "Spread pricing" means any amount charged or claimed by a pharmacy benefit manager
to a health carrier that is in excess of the amount the pharmacy benefit manager paid to the
pharmacy that filled the prescription.
(7) "Trade secrets" has the meaning found in § 6-41-1.