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
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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.