The Vermont Statutes Online

Title 8 : Banking and Insurance

Chapter 107 : Health Insurance

Subchapter 010 : PRESCRIPTION DRUG COVERAGE

• § 4091. Definitions

  As used in this subchapter:

  (1) “Direct solicitation” means direct contact, including telephone, computer, email, instant messaging, or in-person contact, by a pharmacy provider or its agent to an individual covered under a health insurance plan without the covered individual’s consent for the purpose of marketing the pharmacy provider’s services.

  (2) “Health care professional” means an individual licensed to practice medicine under 26 V.S.A. chapter 23 or 33, an individual licensed as a physician assistant under 26 V.S.A. chapter 31, or an individual licensed as an advanced practice registered nurse under 26 V.S.A. chapter 28.

  (3) “Health insurance plan” has the same meaning as in section 4011 of this chapter and includes prescription drug benefits managed by a health insurer or by a pharmacy benefit manager on behalf of a health insurer.

  (4) “Interchangeable biological products” has the same meaning as in 18 V.S.A. § 4601.

  (5) “Out-of-pocket expenditure” means a co-payment, coinsurance, deductible, or other cost-sharing mechanism.

  (6) “Pharmacy benefit manager” means an entity that performs pharmacy benefit management. “Pharmacy benefit management” means an arrangement for the procurement of prescription drugs at negotiated dispensing rates, the administration or management of prescription drug benefits provided by a health insurance 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 management programs.

  (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.

  (8) “Prescription drug” or “drug” has the same meaning as “prescription drug” in 26 V.S.A. § 2022 and includes:

  (A) biological products, as defined in 18 V.S.A. § 4601;

  (B) medications used to treat complex, chronic conditions, including medications that require administration, infusion, or injection by a health care professional;

  (C) medications for which the manufacturer or the U.S. Food and Drug Administration requires exclusive, restricted, or limited distribution; and

  (D) medications with specialized handling, storage, or inventory reporting requirements.

  (9) “Prescription insulin medication” means a prescription drug that contains insulin and is used to treat diabetes.

  (10) “Step therapy” means protocols that establish the specific sequence in which prescription drugs for a specific medical condition are to be prescribed. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)