As used in this chapter, unless the context otherwise requires:
 1. “Clean claim” means a claim that has no defect or impropriety, including a lack of any required substantiating documentation, or other circumstances requiring special treatment, that prevents timely payment from being made on the claim.

Terms Used In Iowa Code 510B.1

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Commissioner: means the commissioner of insurance. See Iowa Code 510B.1
  • Contract: means the same as defined in section 554D. See Iowa Code 554E.1
  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Covered person: means a policyholder, subscriber, or other person participating in a health benefit plan that has a prescription drug benefit managed by a pharmacy benefits manager. See Iowa Code 510B.1
  • Facility: means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. See Iowa Code 510B.1
  • following: when used by way of reference to a chapter or other part of a statute mean the next preceding or next following chapter or other part. See Iowa Code 4.1
  • Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by a third-party payor to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Iowa Code 510B.1
  • Health care professional: means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law. See Iowa Code 510B.1
  • Health care provider: means a health care professional or a facility. See Iowa Code 510B.1
  • Health carrier: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, or a plan established pursuant to chapter 509A for public employees. See Iowa Code 510B.1
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Maximum allowable cost: means the maximum amount that a pharmacy will be reimbursed by a pharmacy benefits manager or a health carrier for a generic drug, brand-name drug, biologic product, or other prescription drug, and that may include any of the following:
     a. See Iowa Code 510B.1
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • person: means individual, corporation, limited liability company, government or governmental subdivision or agency, business trust, estate, trust, partnership or association, or any other legal entity. See Iowa Code 4.1
  • Pharmacist: means the same as defined in section 155A. See Iowa Code 510B.1
  • Pharmacy: means the same as defined in section 155A. See Iowa Code 510B.1
  • Pharmacy benefits manager: means a person who, pursuant to a contract or other relationship with a third-party payor, either directly or through an intermediary, manages a prescription drug benefit provided by the third-party payor. See Iowa Code 510B.1
  • Prescription drug: means the same as defined in section 155A. See Iowa Code 510B.1
  • Prescription drug benefit: means a health benefit plan providing for third-party payment or prepayment for prescription drugs. See Iowa Code 510B.1
  • state: when applied to the different parts of the United States, includes the District of Columbia and the territories, and the words "United States" may include the said district and territories. See Iowa Code 4.1
  • Third-party payor: includes health carriers and other entities that provide a plan of health insurance or health care benefits. See Iowa Code 510B.1
  • Wholesale distributor: means the same as defined in section 155A. See Iowa Code 510B.1
 2. “Commissioner” means the commissioner of insurance.
 3. “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket cost obligation imposed by a health benefit plan on a covered person.
 4. “Covered person” means a policyholder, subscriber, or other person participating in a health benefit plan that has a prescription drug benefit managed by a pharmacy benefits manager.
 5. “Facility” means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
 6. “Health benefit plan” means a policy, contract, certificate, or agreement offered or issued by a third-party payor to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
 7. “Health care professional” means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law.
 8. “Health care provider” means a health care professional or a facility.
 9. “Health carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, or a plan established pursuant to chapter 509A for public employees. “Health carrier” does not include any of the following:

 a. The department of human services.
 b. A managed care organization acting pursuant to a contract with the department of human services to administer the medical assistance program under chapter 249A or the healthy and well kids in Iowa (hawk-i) program under chapter 514I.
 c. A policy or contract providing a prescription drug benefit pursuant to 42 U.S.C. ch. 7, subch. XVIII, part D.
 d. A plan offered or maintained by a multiple employer welfare arrangement established under chapter 513D before January 1, 2022.
 10. “Maximum allowable cost” means the maximum amount that a pharmacy will be reimbursed by a pharmacy benefits manager or a health carrier for a generic drug, brand-name drug, biologic product, or other prescription drug, and that may include any of the following:

 a. Average acquisition cost.
 b. National average acquisition cost.
 c. Average manufacturer price.
 d. Average wholesale price.
 e. Brand effective rate.
 f. Generic effective rate.
 g. Discount indexing.
 h. Federal upper limits.
 i. Wholesale acquisition cost.
 j. Any other term used by a pharmacy benefits manager or a health carrier to establish reimbursement rates for a pharmacy.
 11. “Maximum allowable cost list” means a list of prescription drugs that includes the maximum allowable cost for each prescription drug and that is used, directly or indirectly, by a pharmacy benefits manager.
 12. “Pharmacist” means the same as defined in section 155A.3.
 13. “Pharmacy” means the same as defined in section 155A.3.
 14. “Pharmacy acquisition cost” means the cost to a pharmacy for a prescription drug as invoiced by a wholesale distributor, and reduced by any discounts, rebates, or other price concessions applicable to the prescription drug that are not shown on the invoice and are known at the time that the pharmacy files an appeal with a pharmacy benefits manager.
 15. “Pharmacy benefits manager” means a person who, pursuant to a contract or other relationship with a third-party payor, either directly or through an intermediary, manages a prescription drug benefit provided by the third-party payor.
 16. “Pharmacy benefits manager affiliate” means a pharmacy or a pharmacist that 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 benefits manager.
 17. “Pharmacy network” or “network” means pharmacies that have contracted with a pharmacy benefits manager to dispense or sell prescription drugs to covered persons of a health benefit plan for which the pharmacy benefits manager manages the prescription drug benefit.
 18. “Prescription drug” means the same as defined in section 155A.3.
 19. “Prescription drug benefit” means a health benefit plan providing for third-party payment or prepayment for prescription drugs.
 20. “Prescription drug order” means the same as defined in section 155A.3.
 21. “Rebate” means all discounts and other negotiated price concessions paid directly or indirectly by a pharmaceutical manufacturer or other entity, other than a covered person, in the prescription drug supply chain to a pharmacy benefits manager, and which may be based on any of the following:

 a. A pharmaceutical manufacturer’s list price for a prescription drug.
 b. Utilization.
 c. To maintain a net price for a prescription drug for a specified period of time for the pharmacy benefits manager in the event the pharmaceutical manufacturer’s list price increases.
 d. Reasonable estimates of the volume of a prescribed drug that will be dispensed by a pharmacy to covered persons.
 22. “Third-party payor” means any entity other than a covered person or a health care provider that is responsible for any amount of reimbursement for a prescription drug benefit. “Third-party payor” includes health carriers and other entities that provide a plan of health insurance or health care benefits. “Third-party payor” does not include any of the following:

 a. The department of human services.
 b. A managed care organization acting pursuant to a contract with the department of human services to administer the medical assistance program under chapter 249A or the healthy and well kids in Iowa (hawk-i) program under chapter 514I.
 c. A policy or contract providing a prescription drug benefit pursuant to 42 U.S.C. ch. 7, subch. XVIII, part D.
 23. “Wholesale distributor” means the same as defined in section 155A.3.
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