[431S-1] Definitions. As used in this chapter:

"Commissioner" means the insurance commissioner.

"Covered entity" means:

(1) A health benefits plan regulated under chapter 87A; health insurer regulated under article 10A of chapter 431; mutual benefit society regulated under article 1 of chapter 432; or health maintenance organization regulated under chapter 432D; provided that a "covered entity" under this paragraph shall not include a health maintenance organization regulated under chapter 432D that owns or manages its own pharmacies;

(2) A health program administered by the State in the capacity of a provider of health coverage; or

(3) An employer, labor union, or other group of persons organized in the State that provides health coverage to covered persons employed or residing in the State.

"Covered entity" shall not include any plans issued for coverage for federal employees or specified disease or limited benefit health insurance as provided by section 431:10A-102.5.

"Covered person" means a member, policyholder, subscriber, enrollee, beneficiary, dependent, or other individual participating in a prescription drug benefit plan.

"Person" means an individual, partnership, corporation, organization, or other business entity.

"Pharmacy benefit management" means:

(1) 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 persons;

(C) Clinical formulary development and management services;

(D) Rebate contracting and administration;

(E) Certain patient compliance, therapeutic intervention, and generic substitution programs; or

(F) Disease management programs involving prescription drug utilization;

(2) The procurement of prescription drugs by a pharmacy benefit manager at a negotiated rate for dispensation to covered persons in the State; or

(3) The administration or management of prescription drug benefits provided by a covered entity for the benefit of covered persons.

"Pharmacy benefit manager" means any person that performs pharmacy benefit management, including but not limited to a person or entity in a contractual or employment relationship with a pharmacy benefit manager to perform pharmacy benefit management for a covered entity.

"Prescription drug benefit plan" means a health insurance plan offered by a covered entity that includes coverage for prescription drugs. [L 2017, c 44, pt of 2]

 

 

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