Sec. 21.27.975. Definitions.
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/ak/title-21/chapter-27/21-27-975A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Sec. 21.27.975. Definitions.
In AS 21.27.901 — 21.27.975,
(1)“affiliate” means a business, pharmacy, pharmacist, or provider who, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with a pharmacy benefits manager;
(2)“audit” means an official examination and verification of accounts and records;
(3)“claim” means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or device;
(4)“covered person” means an individual receiving medication coverage or reimbursement provided by an insurer or its pharmacy benefits manager under a health care insurance policy;
(5)“drug” means a prescription drug;
(6)“extrapolation” means the practice of inferring a frequency or dollar amount of overpayments, underpayments, invalid claims, or other errors on any portion of claims submitted, based on the frequency or dollar amount of overpayments, underpayments, invalid claims, or other errors actually measured in a sample of claims;
(7)“insurer” has the meaning given to “health care insurer” in AS 21.54.500 ;
(8)“list” means a list of drugs for which a pharmacy benefits manager has established predetermined reimbursement amounts, or methods for determining reimbursement amounts, to be paid to a network pharmacy or pharmacist for pharmacy services, such as a maximum allowable cost or maximum allowable cost list or any other list of prices used by a pharmacy benefits manager;
(9)“maximum allowable cost” means the maximum amount that a pharmacy benefits manager will reimburse a pharmacy for the cost of a drug;
(10)“national average drug acquisition cost” means the average acquisition cost for outpatient drugs covered by Medicaid, as determined by a monthly survey of retail pharmacies conducted by the federal Centers for Medicare and Medicaid Services;
(11)“network” means an entity that, through contracts or agreements with providers, provides or arranges for access by groups of covered persons to health care services by providers who are not otherwise or individually contracted directly with an insurer or its pharmacy benefits manager;
(12)“network pharmacy” means a pharmacy that provides covered health care services or supplies to an insured or a member under a contract with a network plan to act as a participating provider;
(13)“pharmacy” has the meaning given in AS 08.80.480 ;
(14)“pharmacy acquisition cost” means the amount that a pharmaceutical wholesaler or distributor charges for a pharmaceutical product as listed on the pharmacy's invoice;
(15)“pharmacy benefits manager” means a person that contracts with a pharmacy on behalf of an insurer to process claims or pay pharmacies for prescription drugs or medical devices and supplies or provide network management for pharmacies;
(16)“plan sponsor” has the meaning given in AS 21.54.500 ;
(17)“provider” means a physician, pharmacist, hospital, clinic, hospital outpatient department, pharmacy, or other person licensed or otherwise authorized in this state to furnish health care services;
(18)“recoupment” means the amount that a pharmacy must remit to a pharmacy benefits manager when the pharmacy benefits manager has determined that an overpayment to the pharmacy has occurred;
(19)“wholesale acquisition cost” has the meaning given in 42 U.S.C. 1395w-3a(c)(6)(B).
Article 10. General Provisions.