Section 1: Definitions
436 words·~2 min read·
/ma/part-i/title-xxii/chapter-176y/1·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 1. As used in this chapter, the following words shall have the following meanings unless the context clearly requires otherwise:
''Carrier'', as defined in section 1 of chapter 176O.
''Center'', the center for health information and analysis established in chapter 12C.
''Commissioner'', the commissioner of insurance.
''Division'', the division of insurance.
''Health benefit plan'', a contract, certificate or agreement entered into, offered or issued by a carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services; provided, however, that the commissioner may by regulation define other health coverage as a ''health benefit plan'' for the purposes of this chapter.
''Insured'', as defined in section 1 of chapter 176O.
''Mail-order pharmacy'', a pharmacy whose primary business is to receive prescriptions by mail, telefax or through electronic submissions and to dispense medication to insureds through the use of the United States mail or other common or contract carrier services.
''Pharmacy'', a physical or electronic facility under the direction or supervision of a registered pharmacist that is authorized to dispense prescription drugs and has entered into a network contract with a pharmacy benefit manager or a carrier.
''Pharmacy benefit management services'', services performed by a pharmacy benefit manager, including:
(i)negotiating the price of prescription drugs, including negotiating and contracting for direct or indirect rebates, discounts or other price concessions;
(ii)managing any aspects of a prescription drug benefit, including, but not limited to, formulary administration, mail-order pharmacy and specialty drug pharmacy services, clinical, safety and adherence programs for pharmacy service, the processing and payment of claims for prescription drugs, arranging alternative access to or funding for prescription drugs, the performance of drug utilization review, the processing of drug prior authorization requests, the adjudication of appeals or grievances related to the prescription drug benefit, contracting with network pharmacies, controlling the cost of covered prescription drugs and managing or providing data relating to the prescription drug benefit or the provision of services related thereto;
(iii)performance of any administrative, managerial, clinical, pricing, financial, reimbursement, data administration or reporting or billing service related to a health benefit plan's prescription drug benefit; and
(iv)such other services as the division may define in regulation.
''Pharmacy benefit manager'', a person, business or other entity, however organized, that directly or through a subsidiary provides pharmacy benefit management services for prescription drugs and devices on behalf of a health benefit plan sponsor, including, but not limited to, a self-insurance plan, labor union or other third-party payer; provided, however, that ''pharmacy benefit manager'' shall not include a health benefit plan sponsor unless otherwise specified by the division.