“340B drug” means a drug purchased through the 340B drug discount program by a 340B entity.
Terms Used In Utah Code 31A-46-102
Administrative fee: means any payment, other than a rebate, that a pharmaceutical manufacturer makes directly or indirectly to a pharmacy benefit manager. See Utah Code 31A-46-102
Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
Participating: means a plan of insurance under which the insured is entitled to receive a dividend representing a share of the surplus of the insurer. See Utah Code 31A-1-301
Person: includes :
(a)
an individual;
(b)
a partnership;
(c)
a corporation;
(d)
an incorporated or unincorporated association;
(e)
a joint stock company;
(f)
a trust;
(g)
a limited liability company;
(h)
a reciprocal;
(i)
a syndicate; or
(j)
another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301
Pharmacy benefit manager: means a person licensed under this chapter to provide a pharmacy benefits management service. See Utah Code 31A-46-102
Pharmacy benefits management service: means any of the following services provided to a health benefit plan, or to a participant of a health benefit plan:
(a)
negotiating the amount to be paid by a health benefit plan for a prescription drug; or
(b)
administering or managing a prescription drug benefit provided by the health benefit plan for the benefit of a participant of the health benefit plan, including administering or managing:
(i)
an out-of-state mail service pharmacy;
(ii)
a specialty pharmacy;
(iii)
claims processing;
(iv)
payment of a claim;
(v)
retail network management;
(vi)
clinical formulary development;
(vii)
clinical formulary management services;
(viii)
rebate contracting;
(ix)
rebate administration;
(x)
a participant compliance program;
(xi)
a therapeutic intervention program;
(xii)
a disease management program; or
(xiii)
a service that is similar to, or related to, a service described in Subsection (21)(a) or (21)(b)(i) through (xii). See Utah Code 31A-46-102
Pharmacy services administration organization: means an entity that contracts with a pharmacy to assist with third-party payer interactions and administrative services related to third-party payer interactions, including:
(a)
contracting with a pharmacy benefit manager on behalf of the pharmacy; and
(b)
managing a pharmacy's claims payments from third-party payers. See Utah Code 31A-46-102
Rebate: means a refund, discount, or other price concession that is paid by a pharmaceutical manufacturer to a pharmacy benefit manager based on a prescription drug's utilization or effectiveness. See Utah Code 31A-46-102
Sale: means a prescription drug or prescription device claim covered by a health benefit plan. See Utah Code 31A-46-102
(2)
“340B drug discount program” means the 340B drug discount program described in 42 U.S.C. § 256b.
(3)
“340B entity” means:
(a)
an entity participating in the 340B drug discount program;
(b)
a pharmacy of an entity participating in the 340B drug discount program; or
(c)
a pharmacy contracting with an entity participating in the 340B drug discount program to dispense drugs purchased through the 340B drug discount program.
(4)
“Administrative fee” means any payment, other than a rebate, that a pharmaceutical manufacturer makes directly or indirectly to a pharmacy benefit manager.
(5)
“Allowable claim amount” means the amount paid by an insurer under the customer’s health benefit plan.
(6)
“Contracting insurer” means an insurer with whom a pharmacy benefit manager contracts to provide a pharmacy benefit management service.
(7)
“Cost share” means the amount paid by an insured customer under the customer’s health benefit plan.
(8)
“Device” means the same as that term is defined in Section 58-17b-102.
(9)
“Direct or indirect remuneration” means any adjustment in the total compensation:
(a)
received by a pharmacy from a pharmacy benefit manager for the sale of a drug, device, or other product or service; and
(b)
that is determined after the sale of the product or service.
(10)
“Dispense” means the same as that term is defined in Section 58-17b-102.
(11)
“Drug” means the same as that term is defined in Section 58-17b-102.
(12)
“Insurer” means the same as that term is defined in Section 31A-22-636.
(13)
“Maximum allowable cost” means:
(a)
a maximum reimbursement amount for a group of pharmaceutically and therapeutically equivalent drugs; or
(b)
any similar reimbursement amount that is used by a pharmacy benefit manager to reimburse pharmacies for multiple source drugs.
(14)
“Medicaid program” means the same as that term is defined in Section 26-18-2.
(15)
“Obsolete” means a product that may be listed in national drug pricing compendia but is no longer available to be dispensed based on the expiration date of the last lot manufactured.
(16)
“Patient counseling” means the same as that term is defined in Section 58-17b-102.
(17)
“Pharmaceutical facility” means the same as that term is defined in Section 58-17b-102.
(18)
“Pharmaceutical manufacturer” means a pharmaceutical facility that manufactures prescription drugs.
(19)
“Pharmacist” means the same as that term is defined in Section 58-17b-102.
(20)
“Pharmacy” means the same as that term is defined in Section 58-17b-102.
(21)
“Pharmacy benefits management service” means any of the following services provided to a health benefit plan, or to a participant of a health benefit plan:
(a)
negotiating the amount to be paid by a health benefit plan for a prescription drug; or
(b)
administering or managing a prescription drug benefit provided by the health benefit plan for the benefit of a participant of the health benefit plan, including administering or managing:
(i)
an out-of-state mail service pharmacy;
(ii)
a specialty pharmacy;
(iii)
claims processing;
(iv)
payment of a claim;
(v)
retail network management;
(vi)
clinical formulary development;
(vii)
clinical formulary management services;
(viii)
rebate contracting;
(ix)
rebate administration;
(x)
a participant compliance program;
(xi)
a therapeutic intervention program;
(xii)
a disease management program; or
(xiii)
a service that is similar to, or related to, a service described in Subsection (21)(a) or (21)(b)(i) through (xii).
(22)
“Pharmacy benefit manager” means a person licensed under this chapter to provide a pharmacy benefits management service.
(23)
“Pharmacy service” means a product, good, or service provided to an individual by a pharmacy or pharmacist.
(24)
“Pharmacy services administration organization” means an entity that contracts with a pharmacy to assist with third-party payer interactions and administrative services related to third-party payer interactions, including:
(a)
contracting with a pharmacy benefit manager on behalf of the pharmacy; and
(b)
managing a pharmacy’s claims payments from third-party payers.
(25)
“Pharmacy service entity” means:
(a)
a pharmacy services administration organization; or
(b)
a pharmacy benefit manager.
(26)
“Prescription device” means the same as that term is defined in Section 58-17b-102.
(27)
“Prescription drug” means the same as that term is defined in Section 58-17b-102.
(28)
(a)
“Rebate” means a refund, discount, or other price concession that is paid by a pharmaceutical manufacturer to a pharmacy benefit manager based on a prescription drug’s utilization or effectiveness.
(b)
“Rebate” does not include an administrative fee.
(29)
(a)
“Reimbursement report” means a report on the adjustment in total compensation for a claim.
(b)
“Reimbursement report” does not include a report on adjustments made pursuant to a pharmacy audit or reprocessing.
(30)
“Retail pharmacy” means the same as that term is defined in Section 58-17b-102.
(31)
“Sale” means a prescription drug or prescription device claim covered by a health benefit plan.
(32)
“Wholesale acquisition cost” means the same as that term is defined in 42 U.S.C. § 1395w-3a.
Amended by Chapter 198, 2020 General Session Amended by Chapter 275, 2020 General Session Amended by Chapter 372, 2020 General Session
