44-4603. Terms, defined.

805 words·~4 min read·/ne/chapter-44/44-4603

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

For purposes of the Pharmacy Benefit Manager Licensure and Regulation Act:

(1)Auditing entity means a pharmacy benefit manager or any person that represents a pharmacy benefit manager in conducting an audit for compliance with a contract between the pharmacy benefit manager and a pharmacy;

(2)Claims processing service means an administrative service performed in connection with the processing and adjudicating of a claim relating to a pharmacist service that includes:

(a)Receiving a payment for a pharmacist service; or

(b)Making a payment to a pharmacist or pharmacy for a pharmacist service;

(3)Clinician-administered drug means an outpatient prescription drug other than a vaccine that:

(a)Cannot reasonably be self-administered by the covered person to whom the drug is prescribed or by an individual assisting the covered person with self-administration; and

(b)Is typically administered:

(i)By a health care provider authorized to administer the drug, including when acting under a physician's delegation and supervision; and

(ii)In a physician's office, hospital outpatient infusion center, or other clinical setting;

(4)Covered person means a member, policyholder, subscriber, enrollee, beneficiary, dependent, or other individual participating in a health benefit plan;

(5)Director means the Director of Insurance;

(6)Health benefit plan means a policy, contract, certificate, plan, or agreement entered into, offered, or issued by a health carrier or self-funded employee benefit plan to the extent not preempted by federal law to provide, deliver, arrange for, pay for, or reimburse any of the costs of a physical, mental, or behavioral health care service;

(7)Health carrier has the same meaning as in section 44-1303 ;

(8)Maintenance medication means a drug prescribed for a chronic, long-term condition and taken on a regular, recurring basis;

(9)Network pharmacist means a pharmacist that has a contract, either directly or through a pharmacy services administrative organization, with a pharmacy benefit manager to provide covered drugs at a negotiated reimbursement rate;

(10)Network pharmacy means a pharmacy that has a contract, either directly or through a pharmacy services administrative organization, with a pharmacy benefit manager to provide covered drugs at a negotiated reimbursement rate;

(11)Other prescription drug or device service means a service other than a claims processing service, provided directly or indirectly, whether in connection with or separate from a claims processing service, including, but not limited to:

(a)Negotiating a rebate, discount, or other financial incentive or arrangement with a drug company;

(b)Disbursing or distributing a rebate;

(c)Managing or participating in an incentive program or arrangement for a pharmacist service;

(d)Negotiating or entering into a contractual arrangement with a pharmacist or pharmacy;

(e)Developing and maintaining a formulary;

(f)Designing a prescription benefit program; or

(g)Advertising or promoting a service;

(12)Participating provider has the same meaning as in section 44-7103 ;

(13)Pharmacist has the same meaning as in section 38-2832 ;

(14)Pharmacist service means a product, good, or service or any combination thereof provided as a part of the practice of pharmacy;

(15)Pharmacy has the same meaning as in section 71-425 ;

(16)(a) Pharmacy benefit manager means a person, business, or entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefit manager, that provides a claims processing service or other prescription drug or device service for a health benefit plan to a covered person who is a resident of this state; and

(b)Pharmacy benefit manager does not include:

(i)A health care facility licensed in this state;

(ii)A health care professional licensed in this state;

(iii)A consultant who only provides advice as to the selection or performance of a pharmacy benefit manager; or

(iv)A health carrier to the extent that it performs any claims processing service or other prescription drug or device service exclusively for its enrollees;

(17)Pharmacy benefit manager affiliate means a pharmacy or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a pharmacy benefit manager;

(18)Pharmacy services administrative organization means an entity that provides a contracted pharmacy with contracting administrative services relating to prescription drug benefits;

(19)Plan sponsor has the same meaning as in section 44-2702 ;

(20)Specialty pharmacy means:

(a)A pharmacy that specializes in dispensing drugs for patients with rare or complex medical conditions;

(b)A pharmacy that specializes in prescription drugs that have specific storage or dispensing requirements; or

(c)A pharmacy that holds a specialty pharmacy accreditation from a nationally recognized independent accrediting organization; and

(21)Spread pricing means the method of pricing a drug in which the contracted price for a drug that a pharmacy benefit manager charges a health benefit plan differs from the amount the pharmacy benefit manager directly or indirectly pays the pharmacist or pharmacy for pharmacist services.