Ala. Code § 27-45A-3

Current through the 2024 Regular Session.

Section 27-45A-3 - Definitions

For purposes of this chapter, the following words shall have the following meanings:

(1) CLAIMS PROCESSING SERVICES. The administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include any of the following:

a. Receiving payments for pharmacist services.

b. Making payments to pharmacists or pharmacies for pharmacist services.

c. Both paragraphs a. and b.

(2) COVERED INDIVIDUAL. A member, policyholder, subscriber, enrollee, beneficiary, dependent, or other individual participating in a health benefit plan.

(3) HEALTH BENEFIT PLAN. A policy, contract, certificate, or agreement entered into, offered, or issued by a health insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of physical, mental, or behavioral health care services.

(4) HEALTH INSURER. An entity subject to the insurance laws of this state and rules of the department, or subject to the jurisdiction of the department, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including, but not limited to, a sickness and accident insurance company, a health maintenance organization operating pursuant to Chapter 21A, a nonprofit hospital or health service corporation, a health care service plan organized pursuant to Article 6, Chapter 20 of Title 10A, or any other entity providing a plan of health insurance, health benefits, or health services.

(5) OTHER PRESCRIPTION DRUG OR DEVICE SERVICES. Services, other than claims processing services, provided directly or indirectly, whether in connection with or separate from claims processing services, including, but not limited to, any of the following:

a. Negotiating rebates, discounts, or other financial incentives and arrangements with drug companies.

b. Disbursing or distributing rebates.

c. Managing or participating in incentive programs or arrangements for pharmacist services.

d. Negotiating or entering into contractual arrangements with pharmacists or pharmacies, or both.

e. Developing formularies.

f. Designing prescription benefit programs.

g. Advertising or promoting services.

(6) PHARMACIST. As defined in Section 34-23-1.

(7) PHARMACIST SERVICES. Products, goods, and services, or any combination of products, goods, and services, provided as a part of the practice of pharmacy.

(8) PHARMACY. As defined in Section 34-23-1.

(9) PHARMACY BENEFITS MANAGER.

a. A person, including a wholly or partially owned or controlled subsidiary of a pharmacy benefits manager, that provides claims processing services or other prescription drug or device services, or both, to covered individuals who are employed in or are residents of this state, for health benefit plans.

b. Pharmacy benefits manager does not include any of the following:

1. A healthcare facility licensed in this state.

2. A healthcare professional licensed in this state.

3. A consultant who only provides advice as to the selection or performance of a pharmacy benefits manager.

(10) PBM AFFILIATE. A pharmacy or pharmacist that, directly or indirectly, through one or more intermediaries, is owned or controlled by, or is under common control by, a pharmacy benefits manager.

(11) PRESCRIPTION DRUGS. Includes, but is not limited to, certain infusion, compounded, and long-term care prescription drugs. The term does not include specialty drugs.

(12) SPECIALTY DRUGS. Prescription medications that require special handling, administration, or monitoring and are used for the treatment of patients with serious health conditions requiring complex therapies, and that are eligible for specialty tier placement by the Centers for Medicare and Medicaid Services pursuant to 42 C.F.R. § 423.560.

Ala. Code § 27-45A-3 (1975)

Amended by Act 2021-341,§ 1, eff. 7/1/2021.

Added by Act 2019-457,§ 3, eff. 6/7/2019.