The Vermont Statutes Online

Title 18 : Health

Chapter 221 : Health Care Administration

Subchapter 009 : Pharmacy Benefit Managers

• § 9471. Definitions

  As used in this subchapter:

  (1) “Beneficiary” means an individual enrolled in a health plan in which coverage of prescription drugs is administered by a pharmacy benefit manager and includes his or her dependent or other person provided health coverage through that health plan.

  (2) “Health insurer” is defined by section 9402 of this title and shall include:

  (A) a health insurance company, a nonprofit hospital and medical service corporation, and health maintenance organizations;

  (B) an employer, labor union, or other group of persons organized in Vermont that provides a health plan to beneficiaries who are employed or reside in Vermont; and

  (C) the State of Vermont and any agent or instrumentality of the State that offers, administers, or provides financial support to State government.

  (3) “Health plan” means a health benefit plan offered, administered, or issued by a health insurer doing business in Vermont.

  (4) “Pharmacy benefit management” means an arrangement for the procurement of prescription drugs at a negotiated rate for dispensation within this State to beneficiaries, the administration or management of prescription drug benefits provided by a health plan for the benefit of beneficiaries, 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 beneficiaries;

  (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 or chronic care management programs.

  (5) “Pharmacy benefit manager” means an entity that performs pharmacy benefit management, except an entity that provides pharmacy benefit management services for Vermont Medicaid. The term includes a person or entity in a contractual or employment relationship with an entity performing pharmacy benefit management for a health plan.

  (6) “Maximum allowable cost” means the per unit drug product reimbursement amount, excluding dispensing fees, for a group of equivalent multisource generic prescription drugs.

  (7) “Pharmacy benefit manager affiliate” means a pharmacy or pharmacist that, directly or indirectly, through one or more intermediaries, is owned or controlled by, or is under common ownership or control with, a pharmacy benefit manager. (Added 2007, No. 80, § 8; amended 2013, No. 79, § 21, eff. Jan. 1, 2014; 2015, No. 54, § 2, eff. June 5, 2015; 2021, No. 131 (Adj. Sess.), § 2, eff. January 1, 2023.)