The Vermont Statutes Online

Title 18 : Health

Chapter 077 : Pharmacy Benefit Managers

Subchapter 001 : GENERAL PROVISIONS

• § 3602. Definitions

  As used in this chapter:

  (1) “Claims processing services” means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include receiving payments for pharmacist services or making payments to pharmacists or pharmacies for pharmacy services, or both.

  (2) “Commissioner” means the Commissioner of Financial Regulation.

  (3) “Covered person” means a member, policyholder, subscriber, enrollee, beneficiary, dependent, or other individual participating in a health benefit plan.

  (4) “Health benefit plan” means 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.

  (5) “Health insurer” has the same meaning as in section 9402 of this title and includes:

  (A) health insurance companies, nonprofit hospital and medical service corporations, and health maintenance organizations;

  (B) employers, labor unions, and other group of persons organized in Vermont that provide a health benefit 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.

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

  (7) “Other prescription drug or device services” means services other than claims processing services provided directly or indirectly, whether in connection with or separate from claims processing services, and may include:

  (A) negotiating rebates, price concessions, discounts, or other financial incentives and arrangements with drug companies;

  (B) disbursing or distributing rebates or price concessions, or both;

  (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 and maintaining formularies;

  (F) designing prescription benefit programs; and

  (G) advertising or promoting services.

  (8) “Pharmacist” means an individual licensed as a pharmacist pursuant to 26 V.S.A. chapter 36.

  (9) “Pharmacist services” means products, goods, and services, or a combination of these, provided as part of the practice of pharmacy.

  (10) “Pharmacy” means a place licensed by the Vermont Board of Pharmacy at which drugs, chemicals, medicines, prescriptions, and poisons are compounded, dispensed, or sold at retail.

  (11) “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 benefit 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.

  (12)(A) “Pharmacy benefit manager” means an individual, corporation, or other entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefit manager, that provides pharmacy benefit management services for health benefit plans.

  (B) The term “pharmacy benefit manager” does not include:

  (i) a health care facility licensed in this State;

  (ii) a health care professional licensed in this State;

  (iii) a consultant who only provides advice as to the selection or performance of a pharmacy benefit manager;

  (iv) a health insurer to the extent that it performs any claims processing and other prescription drug or device services exclusively for its enrollees; or

  (v) an entity that provides pharmacy benefit management services for Vermont Medicaid.

  (13) “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 2023, No. 127 (Adj. Sess.), § 1, eff. July 1, 2024.)