Terms used in this chapter mean:
(1)"Brand name," the same as set forth in § 36-11-2 ;
(2)"Covered individual," a member, participant, enrollee, contract holder, policy holder, or beneficiary of a third-party payor who is provided health coverage by the third-party payor. The term includes a dependent or other individual provided health coverage through a policy, contract, or plan for a covered individual;
(3)"Generic drug," a chemically equivalent copy of a brand name drug with an expired patent;
(4)"Health benefit plan," the same as set forth in § 58-17F-2 ;
(5)"Health carrier," the same as set forth in § 58-17F-1 ;
(6)"Interchangeable biological product," the same as set forth in § 36-11-2 ;
(7)"Maximum allowable cost," the maximum amount that a pharmacy may
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Terms used in this chapter mean: (1) "Brand name," the same as set forth in § 36-11-2 ; (2) "Covered individual," a member, participant, enrollee, contract holder, policy holder, or beneficiary of a third-party payor who is provided health coverage by the third-party payor. The term includes a dependent or other individual provided health coverage through a policy, contract, or plan for a covered individual; (3) "Generic drug," a chemically equivalent copy of a brand name drug with an expired patent; (4) "Health benefit plan," the same as set forth in § 58-17F-2 ; (5) "Health carrier," the same as set forth in § 58-17F-1 ; (6) "Interchangeable biological product," the same as set forth in § 36-11-2 ; (7) "Maximum allowable cost," the maximum amount that a pharmacy may be reimbursed, as set by a pharmacy benefit manager or a third-party payor, for a brand name or a generic drug, an interchangeable biological product, or any other prescription drug and which may include: (a) The average acquisition cost; (b) The national average acquisition cost; (c) The average manufacturer price; (d) The average wholesale price; (e) The brand effective rate; (f) The generic effective rate; (g) Discount indexing; (h) Federal upper limits; (i) The wholesale acquisition cost; and (j) Any other term used by a pharmacy benefit manager or a health carrier to establish reimbursement rates for a pharmacy; (8) "Maximum allowable cost list," a list of prescription drugs that: (a) Includes the maximum allowable cost for each prescription drug; and (b) Is used, directly or indirectly, by a pharmacy benefit manager; (9) "Pharmaceutical manufacturer," any person engaged in the business of preparing, producing, converting, processing, packaging, labeling, or distributing a prescription drug, but not including a wholesale distributor or dispenser; (10) "Pharmacist," the same as set forth in § 36-11-2 ; (11) "Pharmacy," the same as set forth in § 36-11-2 ; (12) "Pharmacy benefit management," the procurement of prescription drugs at a negotiated rate for dispensation within this state to covered individuals, the administration or management of prescription drug benefits provided by a third-party payor for the benefit of covered individuals, or any of the following services provided with regard to the administration of pharmacy benefits: (a) Mail service pharmacy; (b) Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals; (c) Clinical formulary development and management services; (d) Rebate contracting and administration; (e) Certain patient compliance, therapeutic intervention, and generic substitution programs; and (f) Disease management programs involving prescription drug utilization; (13) "Pharmacy benefit management fee," a fee that covers the cost of providing pharmacy benefit management, but does not exceed the value of the service performed by the pharmacy benefit manager; (14) "Pharmacy benefit manager," a person that performs pharmacy benefit management, pursuant to a contract or other relationship with a third-party payor and includes: (a) A person acting in a contractual or employment relationship for a pharmacy benefit manager while providing pharmacy benefit management for a third-party payor; and (b) A mail service pharmacy; (15) "Pharmacy benefit manager affiliate," a pharmacy that, or a pharmacist who, directly or indirectly, through one or more intermediaries, owns or controls, is owned and controlled by, or is under common ownership or control of, a pharmacy benefit manager; (16) "Pharmacy network," pharmacies that have contracted with a pharmacy benefit manager to dispense or sell prescription drugs to covered individuals under a health benefit plan for which the prescription drug benefit is managed by a pharmacy benefit manager; (17) "Prescription drug," a drug classified by the United States Food and Drug Administration as requiring a prescription by a health care practitioner, prior to being administered or dispensed to a patient, and including interchangeable biological products, brand names, and generic drugs; (18) "Prescription drug benefit,” a health benefit plan providing third-party payment or prepayment for prescription drugs; (19) "Prescription drug order,” the same as set forth in § 36-11-2 ; (20) "Proprietary information," information on pricing, costs, revenue, taxes, market share, negotiating strategies, customers, and personnel held by a private entity and used for that private entity's business purposes; (21) "Rebate," a discount or other negotiated price concession that is paid directly or indirectly to a pharmacy benefit manager by a pharmaceutical manufacturer or by an entity in the prescription drug supply chain, other than a covered individual, and which is: (a) Based on a pharmaceutical manufacturer's list price for a prescription drug; (b) Based on utilization; (c) Designed to maintain, for the pharmacy benefit manager, a net price for a prescription drug, during a specified period of time, in the event the pharmaceutical manufacturer's list price increases; or (d) Based on estimates regarding the quantity of a prescribed drug that will be dispensed by a pharmacy to covered individuals; (22) "Spread pricing," an amount charged or claimed by a pharmacy benefit manager that is in excess of the ingredient cost for a dispensed prescription drug, plus a dispensing fee paid directly or indirectly to a pharmacy, pharmacist, or other provider, on behalf of the third-party payor, less a pharmacy benefit management fee; (23) "Third-party payor," any entity, other than a covered individual, a covered individual's representative, or a healthcare provider, which is responsible for any amount of reimbursement for a prescription drug benefit, provided the term includes a health carrier and a health benefit plan; (24) "340B drug," a drug purchased through the 340B drug discount program by a 340B entity; (25) "340B drug discount program," a program that imposes limitations on the prices of drugs purchased by covered entities, in accordance with 42 U.S.C. § 256b (January 1, 2024); (26) "340B entity," a covered entity as defined in 42 U.S.C. § 256b(a)(4) (January 1, 2024); (27) "Trade secret," the same as set forth in § 37-29-1 ; (28) "Unaffiliated pharmacy," a dispensing pharmacy that is not: (a) Owned, in whole or in part, by a pharmacy benefit manager; (b) A subsidiary of a pharmacy benefit manager; or (c) An affiliate of a pharmacy benefit manager; and (29) "Wholesale distributor," the same as set forth in § 36-11A-25 .