The Vermont Statutes Online

Title 18 : Health

Chapter 079 : Pharmacy Audits

• § 3801. Definitions

  As used in this subchapter:

  (1)(A) “Health insurer” shall have the same meaning as in section 9402 of this title and shall include:

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

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

  (iii) except as otherwise provided in section 3805 of this title, the State of Vermont and any agent or instrumentality of the State that offers, administers, or provides financial support to State government.

  (B) The term “health insurer” shall not include Medicaid or any other Vermont public health care assistance program.

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

  (3) “Pharmacy” means any individual or entity licensed or registered under 26 V.S.A. chapter 36.

  (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. 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) “Responsible party” means the entity, including a health insurer or pharmacy benefit manager, responsible for payment of claims for health care services other than:

  (A) the individual to whom the health care services were rendered;

  (B) that individual’s guardian or legal representative; or

  (C) the Agency of Human Services, its agents, and contractors. (Added 2011, No. 150 (Adj. Sess.), § 4; amended 2013, No. 79, § 18, eff. Jan. 1, 2014.)