As used in this Subpart, the following definitions apply:
(1)"Drug Shortage List" means a list of drug products posted on the United States
Food and Drug Administration drug shortage website.
(2)"Effective rate pricing" means any payment reduction for pharmacist or pharmacy
services by a pharmacy benefit manager under a reconciliation process for direct or indirect
remuneration fees, a brand or generic effective rate of reimbursement, or any other reduction
or aggregate reduction of payment.
(3)"Health benefit plan", "health plan", "plan", "benefit", or "health insurance
coverage" means services consisting of medical care provided directly through insurance,
reimbursement, or other means, and including items and services paid for as medical care
under any hospital or medical service pol
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As used in this Subpart, the following definitions apply:
(1) "Drug Shortage List" means a list of drug products posted on the United States
Food and Drug Administration drug shortage website.
(2) "Effective rate pricing" means any payment reduction for pharmacist or pharmacy
services by a pharmacy benefit manager under a reconciliation process for direct or indirect
remuneration fees, a brand or generic effective rate of reimbursement, or any other reduction
or aggregate reduction of payment.
(3) "Health benefit plan", "health plan", "plan", "benefit", or "health insurance
coverage" means services consisting of medical care provided directly through insurance,
reimbursement, or other means, and including items and services paid for as medical care
under any hospital or medical service policy or certificate, hospital or medical service plan
contract, preferred provider organization contract, or health maintenance organization
contract offered by a health insurance issuer. However, excepted benefits are not included
as a "health benefit plan".
(4) "Health insurance issuer" means any entity that offers health insurance coverage
through a plan, policy, or certificate of insurance subject to state law that regulates the
business of insurance. "Health insurance issuer" shall also include a health maintenance
organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this
Code.
(5) "Local pharmacy" means a pharmacy as defined in the North American Industry
Classsification System (NAICS) Code 456110, which is domiciled in Louisiana and has
fewer than ten retail outlets under its corporate umbrella.
(6) "Maximum Allowable Cost List" means a listing of the National Drug Code used
by a pharmacy benefit manager setting the maximum allowable cost on which reimbursement
to a pharmacy or pharmacist may be based. "Maximum Allowable Cost List" shall include
any term that a pharmacy benefit manager or a healthcare insurer may use to establish
reimbursement rates for generic and multi-source brand drugs to a pharmacist or pharmacy
for pharmacist services.
(7) "NDC" means the National Drug Code, a numerical identifier assigned to all
prescription drugs.
(8) "Pharmacist" means a licensed pharmacist as defined in R.S. 22:1852.
(9) "Pharmacist services" means products, goods, or services provided as a part of
the practice of pharmacy as defined in R.S. 22:1852.
(10) "Pharmacy" means any appropriately licensed place where prescription drugs
are dispensed as defined in R.S. 22:1852.
(11) "Pharmacy benefit manager" has the same meaning as the term defined in R.S.
22:1641 and includes any person, either directly or indirectly, that provides one or more
pharmacy benefit management services on behalf of an insurer or health plan, and any agent,
contractor, intermediary, affiliate, subsidiary, or related entity of such person who facilitates,
provides, directs, or oversees the provision of the pharmacy benefit management services.
(12) "Pharmacy benefits plan" or "pharmacy benefits program" means a plan or
program that pays for, reimburses, covers the cost of, or otherwise provides for pharmacist
services to individuals who reside in or are employed in Louisiana.
(13) "Rebates" means all rebates, discounts, and other price concessions, based on
utilization of a prescription drug and paid by the manufacturer or other party other than an
enrollee, directly or indirectly, to the pharmacy benefit manager after the claim has been
adjudicated at the pharmacy. Rebates shall include a reasonable estimate, as determined by
the commissioner, of any volume-based discount or other discounts.
(14) "Specialty drug" means a drug that meets all of the following criteria:
(a) The drug is used to treat and is prescribed for a person with a complex, chronic,
or rare medical condition that is progressive, can be debilitating or fatal if left untreated or
undertreated, or for which there is no known cure.
(b) The drug is not routinely stocked at a majority of pharmacies within this state.
(c) The drug has special handling, storage, inventory, or distribution requirements.
(d) Patients receiving the drug require complex education and treatment maintenance,
such as complex dosing, intensive monitoring, or clinical oversight.
(15) "Spread pricing" means any amount charged or claimed by a pharmacy benefit
manager for a prescription drug that exceeds the amount paid by the pharmacy benefit
manager to the pharmacist or pharmacy for the dispensing of the prescription drug, minus
a pharmacy benefit management fee.