(1) As used in this subchapter:(1) (A) “Affiliate” means an entity that controls, is controlled by, or is under common control with another entity, including an entity in which control is established through one (1) or more intermediary entities, such that the common controlling interest may be two (2) or more levels removed from the specified entity.(B) Whether an entity is an “affiliate” does not depend on the percentage or form of ownership interest or any allocation of membership or ownership between entities, but it is the existence of control or common control that is the sole determinative factor;(2) (A) “Carve-out network” means a subset of a pharmacy benefits manager's network that:(i) Is created by the pharmacy benefits manager; and(ii) Limits access to a certain pharmacy or pharmacist for a specific drug or category of drugs.(B) “Carve-out network” includes any network that restricts enrollee access to in-person pharmacy services within this state by offering only limited methods of obtaining a prescription drug, including mail-order only options, while presenting the appearance of a full network of available pharmacies;(3) “Claims processing services” means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include:(A) Receiving payments for pharmacist services;(B) Making payments to pharmacists or pharmacies for pharmacist services; or(C) Both subdivisions (3)(A) and (B) of this section;(4) (A) “Clean claim” or “clean pharmacy claim” means a pharmacy claim that does not have a defect, including without limitation a lack of any required substantiating documentation or particular circumstance requiring special treatment that may prevent timely payment of the pharmacy claim.(B) “Clean claim” or “clean pharmacy claim” includes an electronic pharmacy claim that successfully processes in real time with an approval of drug, dosing, prescriber, or patient eligibility upon an electronic adjudication of a pharmacy claim with the displayed paid amount from the pharmacy benefits manager and the patient copay.(C) “Clean claim” or “clean pharmacy claim” does not include a successfully adjudicated pharmacy claim that the pharmacy or pharmacist obtained by fraud or a clerical error or misrepresentation of the pharmacy claim elements;(5) “Date of the receipt of a claim” means a claim that is considered to have been received:(A) For an electronic claim, on the date on which the claim is transferred; or(B) For other manual or paper claim, on the fifth day after the postmark date of the claim or the date specified in the time stamp of the transmission, whichever is sooner;(6) “Enrollee” means an individual who is entitled to receive healthcare services under the terms of a health benefit plan;(7) (A) “Ghost network” means a pharmacy benefits manager network that includes a pharmacy or pharmacist as a participating provider when that participating provider is:(i) Not accepting new patients;(ii) No longer in practice; or(iii) Otherwise unavailable to or restricted from providing services to enrollees in this state.(B) “Ghost network” includes a pharmacy network in which a significant number of listed participating providers are not accessible to enrollees within a reasonable time frame or geographic distance;(8) (A) “Health benefit plan” means any individual, blanket, or group plan, policy, or contract for healthcare services issued or delivered by a healthcare payor to residents of this state.(B) “Health benefit plan” does not include:(i) Accident-only plans;(ii) Specified disease plans;(iii) Disability income plans;(iv) Plans that provide only for indemnity for hospital confinement;(v) Long-term care only plans that do not include pharmacy benefits;(vi) Other limited-benefit health insurance policies or plans; or(vii) Health benefit plans provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., and the Public Employee Workers' Compensation Act, § 21-5-601 et seq.(C) “Health benefit plan” includes any group plan, policy, or contract for healthcare services issued outside this state that provides benefits to residents of this state;(9) “Healthcare payor” means:(A) A health insurance company;(B) A health maintenance organization;(C) A hospital and medical services corporation; and(D) An entity that provides or administers a self-funded health benefit plan, including a governmental plan;(10) “Healthcare payor affiliate” means a pharmacy or pharmacist that directly or indirectly, through one (1) or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a healthcare payor;(11) “Material alteration to a contract” means a change to a contract or addendum to a contract that shall be made explicitly and shall not be made by reference through a pharmacy provider manual;(12) (A) “Opt-out contract” means an agreement or a contract in which a pharmacy must proactively notify the pharmacy benefits manager if the pharmacy wishes to opt-out of certain terms potentially leading to lower reimbursement rates or network exclusions if the pharmacy does not opt-out of the contract.(B) “Opt-out contract” includes a term that requires a pharmacy to take affirmative action to opt-out of certain terms or conditions of the contract;(13) “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, including without limitation:(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; or(G) Advertising or promoting services;(14) “Pharmacist” means an individual licensed as a pharmacist by the Arkansas State Board of Pharmacy;(15) “Pharmacist services” means products, goods, and services, or any combination of products, goods, and services, provided as a part of the practice of pharmacy as defined in § 17-92-101;(16) “Pharmacy” means the same as defined in § 17-92-101;(17) (A) “Pharmacy benefits management services” means the management or administration of a plan or program that:(i) Pays or reimburses for a price and covers the cost of prescription drugs and medical devices;(ii) Includes the processing and payment of claims for prescription drugs and the adjudication of appeals or grievances related to the prescription drug benefit;(iii) Includes electronic or manual processing and payment of claims through the adjudication of prescription drug manufacturer coupons or prescription drug manufacturer discounts; or(iv) Includes prescription discount card services, processing, electronic adjudication, or payment of claims for prescription drugs by a discount card or discount card processor in situations in which a vendor that otherwise identifies itself as a discount card vendor has been subcontracted or contracted directly or indirectly by another licensed pharmacy benefits manager or healthcare payor.(B) “Pharmacy benefits management services” does not include a prescription discount card service if the:(i) Entire amount is paid by the patient, and the individual pharmacy has directly contracted with the prescription discount card service for each individual pharmacy and not through a pharmacy services administrative organization or a leased pharmacy benefits manager network; or(ii) Entire amount is paid by the patient, and the discount card is an in-house pharmacy discount card;(18) (A) “Pharmacy benefits manager” means a person, business, or entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefits manager, that provides claims processing services, pharmacy benefits management services, or other prescription drug or device services, or any combination of the three (3), for health benefit plans.(B) “Pharmacy benefits manager” does not include any:(i) Healthcare facility licensed in Arkansas;(ii) Healthcare professional licensed in Arkansas;(iii) Consultant who only provides advice as to the selection or performance of a pharmacy benefits manager; or(iv) Entity that provides claims processing services or other prescription drug or device services for the fee-for-service Arkansas Medicaid Program only in that capacity;(19) “Pharmacy benefits manager affiliate” means a pharmacy or pharmacist that directly or indirectly, through one (1) or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a pharmacy benefits manager;(20) (A) “Pharmacy benefits manager national contract to pharmacies” means a standardized agreement entered into by a pharmacy benefits manager and a network of pharmacies across the United States in which a pharmacy is, either directly or indirectly, passed through a pharmacy services administrative organization messenger model to agree to certain pricing terms and conditions for a patient if that pharmacy is managed or represented by a pharmacy benefits manager network.(B) “Pharmacy benefits manager national contract to pharmacies” includes a nationwide network of pharmacies that have entered into a contract for national reimbursement rates, terms, and conditions that are not Arkansas-specific with a pharmacy benefits manager to provide pharmacist services, including without limitation dispensing medications to a patient within the pharmacy benefits manager network;(21) “Pharmacy benefits manager network” means a network of pharmacists or pharmacies that are offered by an agreement or insurance contract to provide pharmacist services for health benefit plans;(22) “Pharmacy benefits plan or program” means a plan or program that pays for, reimburses, covers the cost of, or otherwise provides for pharmacist services under a health benefit plan;(23) (A) “Pharmacy claims bank identification number” means a six-digit number or an eight-digit number from the National Council for Prescription Drug Programs Processor ID Number bank identification number that is utilized and shared by a pharmacy benefits manager to electronically process a pharmacy claim.(B) “Pharmacy claims bank identification number” may be known as RXBIN or NCPDP Processor BIN;(24) (A) “Pharmacy claims group number” means a unique set of numbers and letters that are used by a pharmacy benefits manager to identify a specific employer, plan sponsor, insurance provider, or plan type that a patient is enrolled in to cover and reimburse a pharmacy or a pharmacist for pharmacist services.(B) “Pharmacy claims group number” may be known as an RxGroup number or a prescription group number;(25) (A) “Pharmacy claims processor control number” means a secondary identifier that is alphanumerical and clarifies the pharmacy claim to a specific network or plan type that a pharmacy benefits manager may use in processing a pharmacy claim for pharmacist services.(B) “Pharmacy claims processor control number” may be known as PCN or RxPCN;(26) (A) “Pharmacy provider manual” means a document provided by a pharmacy benefits manager to a pharmacist or pharmacy that may provide contracted pharmacy providers with information about regulations, administrative procedures, billing instructions, information on how to meet the pharmacist's or pharmacy's contractual obligations, contact information, audit information, maximum allowable cost appeals, pricing appeals, and other details about various networks managed by the pharmacy benefits manager.(B) “Pharmacy provider manual” does not include a material alteration to a contract that shall be made explicitly in a contract or addendum;(27) “Pharmacy services administrative organization” means an organization that helps community pharmacies and pharmacy benefits managers or third-party payers achieve administrative efficiencies, including contracting and payment efficiencies;(28) (A) “Place on probation” means an enforcement action against a pharmacy benefits manager for lack of compliance with the requirements of this subchapter.(B) “Place on probation” includes penalties of probation and may include:(i) Prohibiting on advertising or bidding on new business or requests for proposals;(ii) Requiring notification of probation to a current contracted plan or program that is directly or indirectly funded by a state appropriation to furnish, cover the cost of, or otherwise provide for pharmacist services to an individual who resides in or is employed in this state; or(iii) Other penalties established by rule of the Insurance Commissioner;(29) (A) “Prescription drug manufacturer” or “pharmaceutical manufacturer” means a business or entity that makes, processes, or packages prescription drugs, over-the-counter medications, or medical devices to sell in a pharmacy or other healthcare facility.(B) “Prescription drug manufacturer” or “pharmaceutical manufacturer” includes an entity that manipulates, tests, or controls the product or process;(30) “Prescription drug manufacturer coupon” or “pharmaceutical manufacturer coupon” means a prescription drug discount that is:(A) Utilized to reduce the cost of prescription medications in a pharmacy at the point of sale in the form of copayment reduction, discount, e-voucher, electronic voucher, or a card to help a consumer reduce the out-of-pocket costs, including without limitation a copayment and coinsurance, or otherwise lower the overall cost of prescription drugs; and(B) Sponsored or provided by a prescription drug manufacturer or pharmaceutical manufacturer usually through a vendor or an electronic claims processor;(31) (A) “Rebate” means a discount or other price concession, or a payment that is:(i) Based on utilization of a prescription drug; and(ii) Paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefits manager, pharmacy services administrative organization, or pharmacy after a claim has been processed and paid at a pharmacy.(B) “Rebate” includes without limitation incentives, disbursements, and reasonable estimates of a volume-based discount;(32) (A) “Self-administered prescription drug” means a pharmaceutical that when prescribed does not require assistance by a third party to administer and can be dispensed by a pharmacy or pharmacist to an enrollee for self-administration under federal and state laws and regulations.(B) “Self-administered prescription drug” does not include over-the-counter medications that do not require a prescription;(33) “Spread pricing” means the model of prescription drug pricing in which the pharmacy benefits manager charges a health benefit plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the pharmacy benefits manager directly or indirectly pays the pharmacist or pharmacy for pharmacist services;(34) “Third party” means a person, business, or entity other than a pharmacy benefits manager that is not an enrollee or insured in a health benefit plan;(35) “Underpayment violation” means:(A) A violation of § 23-92-506(b);(B) A violation of § 17-92-507; or(C) A fair and reasonable compensation payment violation as defined under § 23-92-506(a) and by rule of the commissioner; and(36) “Unique combination for pharmacy claims” means a pharmacy claims bank identification number, pharmacy claims group number, pharmacy claims processor control number, or any combination of a pharmacy claims bank identification number, pharmacy claims group number, and pharmacy claims processor control number that is used by a pharmacy benefits manager to process a pharmacy claim.
(1) (A) “Affiliate” means an entity that controls, is controlled by, or is under common control with another entity, including an entity in which control is established through one (1) or more intermediary entities, such that the common controlling interest may be two (2) or more levels removed from the specified entity.(B) Whether an entity is an “affiliate” does not depend on the percentage or form of ownership interest or any allocation of membership or ownership between entities, but it is the existence of control or common control that is the sole determinative factor;
(A) “Affiliate” means an entity that controls, is controlled by, or is under common control with another entity, including an entity in which control is established through one (1) or more intermediary entities, such that the common controlling interest may be two (2) or more levels removed from the specified entity.
(B) Whether an entity is an “affiliate” does not depend on the percentage or form of ownership interest or any allocation of membership or ownership between entities, but it is the existence of control or common control that is the sole determinative factor;
(2) (A) “Carve-out network” means a subset of a pharmacy benefits manager's network that:(i) Is created by the pharmacy benefits manager; and(ii) Limits access to a certain pharmacy or pharmacist for a specific drug or category of drugs.(B) “Carve-out network” includes any network that restricts enrollee access to in-person pharmacy services within this state by offering only limited methods of obtaining a prescription drug, including mail-order only options, while presenting the appearance of a full network of available pharmacies;
(A) “Carve-out network” means a subset of a pharmacy benefits manager's network that:(i) Is created by the pharmacy benefits manager; and(ii) Limits access to a certain pharmacy or pharmacist for a specific drug or category of drugs.
(i) Is created by the pharmacy benefits manager; and
(ii) Limits access to a certain pharmacy or pharmacist for a specific drug or category of drugs.
(B) “Carve-out network” includes any network that restricts enrollee access to in-person pharmacy services within this state by offering only limited methods of obtaining a prescription drug, including mail-order only options, while presenting the appearance of a full network of available pharmacies;
(3) “Claims processing services” means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include:(A) Receiving payments for pharmacist services;(B) Making payments to pharmacists or pharmacies for pharmacist services; or(C) Both subdivisions (3)(A) and (B) of this section;
(A) Receiving payments for pharmacist services;
(B) Making payments to pharmacists or pharmacies for pharmacist services; or
(C) Both subdivisions (3)(A) and (B) of this section;
(4) (A) “Clean claim” or “clean pharmacy claim” means a pharmacy claim that does not have a defect, including without limitation a lack of any required substantiating documentation or particular circumstance requiring special treatment that may prevent timely payment of the pharmacy claim.(B) “Clean claim” or “clean pharmacy claim” includes an electronic pharmacy claim that successfully processes in real time with an approval of drug, dosing, prescriber, or patient eligibility upon an electronic adjudication of a pharmacy claim with the displayed paid amount from the pharmacy benefits manager and the patient copay.(C) “Clean claim” or “clean pharmacy claim” does not include a successfully adjudicated pharmacy claim that the pharmacy or pharmacist obtained by fraud or a clerical error or misrepresentation of the pharmacy claim elements;
(A) “Clean claim” or “clean pharmacy claim” means a pharmacy claim that does not have a defect, including without limitation a lack of any required substantiating documentation or particular circumstance requiring special treatment that may prevent timely payment of the pharmacy claim.
(B) “Clean claim” or “clean pharmacy claim” includes an electronic pharmacy claim that successfully processes in real time with an approval of drug, dosing, prescriber, or patient eligibility upon an electronic adjudication of a pharmacy claim with the displayed paid amount from the pharmacy benefits manager and the patient copay.
(C) “Clean claim” or “clean pharmacy claim” does not include a successfully adjudicated pharmacy claim that the pharmacy or pharmacist obtained by fraud or a clerical error or misrepresentation of the pharmacy claim elements;
(5) “Date of the receipt of a claim” means a claim that is considered to have been received:(A) For an electronic claim, on the date on which the claim is transferred; or(B) For other manual or paper claim, on the fifth day after the postmark date of the claim or the date specified in the time stamp of the transmission, whichever is sooner;
(A) For an electronic claim, on the date on which the claim is transferred; or
(B) For other manual or paper claim, on the fifth day after the postmark date of the claim or the date specified in the time stamp of the transmission, whichever is sooner;
(6) “Enrollee” means an individual who is entitled to receive healthcare services under the terms of a health benefit plan;
(7) (A) “Ghost network” means a pharmacy benefits manager network that includes a pharmacy or pharmacist as a participating provider when that participating provider is:(i) Not accepting new patients;(ii) No longer in practice; or(iii) Otherwise unavailable to or restricted from providing services to enrollees in this state.(B) “Ghost network” includes a pharmacy network in which a significant number of listed participating providers are not accessible to enrollees within a reasonable time frame or geographic distance;
(A) “Ghost network” means a pharmacy benefits manager network that includes a pharmacy or pharmacist as a participating provider when that participating provider is:(i) Not accepting new patients;(ii) No longer in practice; or(iii) Otherwise unavailable to or restricted from providing services to enrollees in this state.
(i) Not accepting new patients;
(ii) No longer in practice; or
(iii) Otherwise unavailable to or restricted from providing services to enrollees in this state.
(B) “Ghost network” includes a pharmacy network in which a significant number of listed participating providers are not accessible to enrollees within a reasonable time frame or geographic distance;
(8) (A) “Health benefit plan” means any individual, blanket, or group plan, policy, or contract for healthcare services issued or delivered by a healthcare payor to residents of this state.(B) “Health benefit plan” does not include:(i) Accident-only plans;(ii) Specified disease plans;(iii) Disability income plans;(iv) Plans that provide only for indemnity for hospital confinement;(v) Long-term care only plans that do not include pharmacy benefits;(vi) Other limited-benefit health insurance policies or plans; or(vii) Health benefit plans provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., and the Public Employee Workers' Compensation Act, § 21-5-601 et seq.(C) “Health benefit plan” includes any group plan, policy, or contract for healthcare services issued outside this state that provides benefits to residents of this state;
(A) “Health benefit plan” means any individual, blanket, or group plan, policy, or contract for healthcare services issued or delivered by a healthcare payor to residents of this state.
(B) “Health benefit plan” does not include:(i) Accident-only plans;(ii) Specified disease plans;(iii) Disability income plans;(iv) Plans that provide only for indemnity for hospital confinement;(v) Long-term care only plans that do not include pharmacy benefits;(vi) Other limited-benefit health insurance policies or plans; or(vii) Health benefit plans provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., and the Public Employee Workers' Compensation Act, § 21-5-601 et seq.
(i) Accident-only plans;
(ii) Specified disease plans;
(iii) Disability income plans;
(iv) Plans that provide only for indemnity for hospital confinement;
(v) Long-term care only plans that do not include pharmacy benefits;
(vi) Other limited-benefit health insurance policies or plans; or
(vii) Health benefit plans provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., and the Public Employee Workers' Compensation Act, § 21-5-601 et seq.
(C) “Health benefit plan” includes any group plan, policy, or contract for healthcare services issued outside this state that provides benefits to residents of this state;
(9) “Healthcare payor” means:(A) A health insurance company;(B) A health maintenance organization;(C) A hospital and medical services corporation; and(D) An entity that provides or administers a self-funded health benefit plan, including a governmental plan;
(A) A health insurance company;
(B) A health maintenance organization;
(C) A hospital and medical services corporation; and
(D) An entity that provides or administers a self-funded health benefit plan, including a governmental plan;
(10) “Healthcare payor affiliate” means a pharmacy or pharmacist that directly or indirectly, through one (1) or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a healthcare payor;
(11) “Material alteration to a contract” means a change to a contract or addendum to a contract that shall be made explicitly and shall not be made by reference through a pharmacy provider manual;
(12) (A) “Opt-out contract” means an agreement or a contract in which a pharmacy must proactively notify the pharmacy benefits manager if the pharmacy wishes to opt-out of certain terms potentially leading to lower reimbursement rates or network exclusions if the pharmacy does not opt-out of the contract.(B) “Opt-out contract” includes a term that requires a pharmacy to take affirmative action to opt-out of certain terms or conditions of the contract;
(A) “Opt-out contract” means an agreement or a contract in which a pharmacy must proactively notify the pharmacy benefits manager if the pharmacy wishes to opt-out of certain terms potentially leading to lower reimbursement rates or network exclusions if the pharmacy does not opt-out of the contract.
(B) “Opt-out contract” includes a term that requires a pharmacy to take affirmative action to opt-out of certain terms or conditions of the contract;
(13) “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, including without limitation:(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; or(G) Advertising or promoting services;
(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; or
(G) Advertising or promoting services;
(14) “Pharmacist” means an individual licensed as a pharmacist by the Arkansas State Board of Pharmacy;
(15) “Pharmacist services” means products, goods, and services, or any combination of products, goods, and services, provided as a part of the practice of pharmacy as defined in § 17-92-101;
(16) “Pharmacy” means the same as defined in § 17-92-101;
(17) (A) “Pharmacy benefits management services” means the management or administration of a plan or program that:(i) Pays or reimburses for a price and covers the cost of prescription drugs and medical devices;(ii) Includes the processing and payment of claims for prescription drugs and the adjudication of appeals or grievances related to the prescription drug benefit;(iii) Includes electronic or manual processing and payment of claims through the adjudication of prescription drug manufacturer coupons or prescription drug manufacturer discounts; or(iv) Includes prescription discount card services, processing, electronic adjudication, or payment of claims for prescription drugs by a discount card or discount card processor in situations in which a vendor that otherwise identifies itself as a discount card vendor has been subcontracted or contracted directly or indirectly by another licensed pharmacy benefits manager or healthcare payor.(B) “Pharmacy benefits management services” does not include a prescription discount card service if the:(i) Entire amount is paid by the patient, and the individual pharmacy has directly contracted with the prescription discount card service for each individual pharmacy and not through a pharmacy services administrative organization or a leased pharmacy benefits manager network; or(ii) Entire amount is paid by the patient, and the discount card is an in-house pharmacy discount card;
(A) “Pharmacy benefits management services” means the management or administration of a plan or program that:(i) Pays or reimburses for a price and covers the cost of prescription drugs and medical devices;(ii) Includes the processing and payment of claims for prescription drugs and the adjudication of appeals or grievances related to the prescription drug benefit;(iii) Includes electronic or manual processing and payment of claims through the adjudication of prescription drug manufacturer coupons or prescription drug manufacturer discounts; or(iv) Includes prescription discount card services, processing, electronic adjudication, or payment of claims for prescription drugs by a discount card or discount card processor in situations in which a vendor that otherwise identifies itself as a discount card vendor has been subcontracted or contracted directly or indirectly by another licensed pharmacy benefits manager or healthcare payor.
(i) Pays or reimburses for a price and covers the cost of prescription drugs and medical devices;
(ii) Includes the processing and payment of claims for prescription drugs and the adjudication of appeals or grievances related to the prescription drug benefit;
(iii) Includes electronic or manual processing and payment of claims through the adjudication of prescription drug manufacturer coupons or prescription drug manufacturer discounts; or
(iv) Includes prescription discount card services, processing, electronic adjudication, or payment of claims for prescription drugs by a discount card or discount card processor in situations in which a vendor that otherwise identifies itself as a discount card vendor has been subcontracted or contracted directly or indirectly by another licensed pharmacy benefits manager or healthcare payor.
(B) “Pharmacy benefits management services” does not include a prescription discount card service if the:(i) Entire amount is paid by the patient, and the individual pharmacy has directly contracted with the prescription discount card service for each individual pharmacy and not through a pharmacy services administrative organization or a leased pharmacy benefits manager network; or(ii) Entire amount is paid by the patient, and the discount card is an in-house pharmacy discount card;
(i) Entire amount is paid by the patient, and the individual pharmacy has directly contracted with the prescription discount card service for each individual pharmacy and not through a pharmacy services administrative organization or a leased pharmacy benefits manager network; or
(ii) Entire amount is paid by the patient, and the discount card is an in-house pharmacy discount card;
(18) (A) “Pharmacy benefits manager” means a person, business, or entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefits manager, that provides claims processing services, pharmacy benefits management services, or other prescription drug or device services, or any combination of the three (3), for health benefit plans.(B) “Pharmacy benefits manager” does not include any:(i) Healthcare facility licensed in Arkansas;(ii) Healthcare professional licensed in Arkansas;(iii) Consultant who only provides advice as to the selection or performance of a pharmacy benefits manager; or(iv) Entity that provides claims processing services or other prescription drug or device services for the fee-for-service Arkansas Medicaid Program only in that capacity;
(A) “Pharmacy benefits manager” means a person, business, or entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefits manager, that provides claims processing services, pharmacy benefits management services, or other prescription drug or device services, or any combination of the three (3), for health benefit plans.
(B) “Pharmacy benefits manager” does not include any:(i) Healthcare facility licensed in Arkansas;(ii) Healthcare professional licensed in Arkansas;(iii) Consultant who only provides advice as to the selection or performance of a pharmacy benefits manager; or(iv) Entity that provides claims processing services or other prescription drug or device services for the fee-for-service Arkansas Medicaid Program only in that capacity;
(i) Healthcare facility licensed in Arkansas;
(ii) Healthcare professional licensed in Arkansas;
(iii) Consultant who only provides advice as to the selection or performance of a pharmacy benefits manager; or
(iv) Entity that provides claims processing services or other prescription drug or device services for the fee-for-service Arkansas Medicaid Program only in that capacity;
(19) “Pharmacy benefits manager affiliate” means a pharmacy or pharmacist that directly or indirectly, through one (1) or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a pharmacy benefits manager;
(20) (A) “Pharmacy benefits manager national contract to pharmacies” means a standardized agreement entered into by a pharmacy benefits manager and a network of pharmacies across the United States in which a pharmacy is, either directly or indirectly, passed through a pharmacy services administrative organization messenger model to agree to certain pricing terms and conditions for a patient if that pharmacy is managed or represented by a pharmacy benefits manager network.(B) “Pharmacy benefits manager national contract to pharmacies” includes a nationwide network of pharmacies that have entered into a contract for national reimbursement rates, terms, and conditions that are not Arkansas-specific with a pharmacy benefits manager to provide pharmacist services, including without limitation dispensing medications to a patient within the pharmacy benefits manager network;
(A) “Pharmacy benefits manager national contract to pharmacies” means a standardized agreement entered into by a pharmacy benefits manager and a network of pharmacies across the United States in which a pharmacy is, either directly or indirectly, passed through a pharmacy services administrative organization messenger model to agree to certain pricing terms and conditions for a patient if that pharmacy is managed or represented by a pharmacy benefits manager network.
(B) “Pharmacy benefits manager national contract to pharmacies” includes a nationwide network of pharmacies that have entered into a contract for national reimbursement rates, terms, and conditions that are not Arkansas-specific with a pharmacy benefits manager to provide pharmacist services, including without limitation dispensing medications to a patient within the pharmacy benefits manager network;
(21) “Pharmacy benefits manager network” means a network of pharmacists or pharmacies that are offered by an agreement or insurance contract to provide pharmacist services for health benefit plans;
(22) “Pharmacy benefits plan or program” means a plan or program that pays for, reimburses, covers the cost of, or otherwise provides for pharmacist services under a health benefit plan;
(23) (A) “Pharmacy claims bank identification number” means a six-digit number or an eight-digit number from the National Council for Prescription Drug Programs Processor ID Number bank identification number that is utilized and shared by a pharmacy benefits manager to electronically process a pharmacy claim.(B) “Pharmacy claims bank identification number” may be known as RXBIN or NCPDP Processor BIN;
(A) “Pharmacy claims bank identification number” means a six-digit number or an eight-digit number from the National Council for Prescription Drug Programs Processor ID Number bank identification number that is utilized and shared by a pharmacy benefits manager to electronically process a pharmacy claim.
(B) “Pharmacy claims bank identification number” may be known as RXBIN or NCPDP Processor BIN;
(24) (A) “Pharmacy claims group number” means a unique set of numbers and letters that are used by a pharmacy benefits manager to identify a specific employer, plan sponsor, insurance provider, or plan type that a patient is enrolled in to cover and reimburse a pharmacy or a pharmacist for pharmacist services.(B) “Pharmacy claims group number” may be known as an RxGroup number or a prescription group number;
(A) “Pharmacy claims group number” means a unique set of numbers and letters that are used by a pharmacy benefits manager to identify a specific employer, plan sponsor, insurance provider, or plan type that a patient is enrolled in to cover and reimburse a pharmacy or a pharmacist for pharmacist services.
(B) “Pharmacy claims group number” may be known as an RxGroup number or a prescription group number;
(25) (A) “Pharmacy claims processor control number” means a secondary identifier that is alphanumerical and clarifies the pharmacy claim to a specific network or plan type that a pharmacy benefits manager may use in processing a pharmacy claim for pharmacist services.(B) “Pharmacy claims processor control number” may be known as PCN or RxPCN;
(A) “Pharmacy claims processor control number” means a secondary identifier that is alphanumerical and clarifies the pharmacy claim to a specific network or plan type that a pharmacy benefits manager may use in processing a pharmacy claim for pharmacist services.
(B) “Pharmacy claims processor control number” may be known as PCN or RxPCN;
(26) (A) “Pharmacy provider manual” means a document provided by a pharmacy benefits manager to a pharmacist or pharmacy that may provide contracted pharmacy providers with information about regulations, administrative procedures, billing instructions, information on how to meet the pharmacist's or pharmacy's contractual obligations, contact information, audit information, maximum allowable cost appeals, pricing appeals, and other details about various networks managed by the pharmacy benefits manager.(B) “Pharmacy provider manual” does not include a material alteration to a contract that shall be made explicitly in a contract or addendum;
(A) “Pharmacy provider manual” means a document provided by a pharmacy benefits manager to a pharmacist or pharmacy that may provide contracted pharmacy providers with information about regulations, administrative procedures, billing instructions, information on how to meet the pharmacist's or pharmacy's contractual obligations, contact information, audit information, maximum allowable cost appeals, pricing appeals, and other details about various networks managed by the pharmacy benefits manager.
(B) “Pharmacy provider manual” does not include a material alteration to a contract that shall be made explicitly in a contract or addendum;
(27) “Pharmacy services administrative organization” means an organization that helps community pharmacies and pharmacy benefits managers or third-party payers achieve administrative efficiencies, including contracting and payment efficiencies;
(28) (A) “Place on probation” means an enforcement action against a pharmacy benefits manager for lack of compliance with the requirements of this subchapter.(B) “Place on probation” includes penalties of probation and may include:(i) Prohibiting on advertising or bidding on new business or requests for proposals;(ii) Requiring notification of probation to a current contracted plan or program that is directly or indirectly funded by a state appropriation to furnish, cover the cost of, or otherwise provide for pharmacist services to an individual who resides in or is employed in this state; or(iii) Other penalties established by rule of the Insurance Commissioner;
(A) “Place on probation” means an enforcement action against a pharmacy benefits manager for lack of compliance with the requirements of this subchapter.
(B) “Place on probation” includes penalties of probation and may include:(i) Prohibiting on advertising or bidding on new business or requests for proposals;(ii) Requiring notification of probation to a current contracted plan or program that is directly or indirectly funded by a state appropriation to furnish, cover the cost of, or otherwise provide for pharmacist services to an individual who resides in or is employed in this state; or(iii) Other penalties established by rule of the Insurance Commissioner;
(i) Prohibiting on advertising or bidding on new business or requests for proposals;
(ii) Requiring notification of probation to a current contracted plan or program that is directly or indirectly funded by a state appropriation to furnish, cover the cost of, or otherwise provide for pharmacist services to an individual who resides in or is employed in this state; or
(iii) Other penalties established by rule of the Insurance Commissioner;
(29) (A) “Prescription drug manufacturer” or “pharmaceutical manufacturer” means a business or entity that makes, processes, or packages prescription drugs, over-the-counter medications, or medical devices to sell in a pharmacy or other healthcare facility.(B) “Prescription drug manufacturer” or “pharmaceutical manufacturer” includes an entity that manipulates, tests, or controls the product or process;
(A) “Prescription drug manufacturer” or “pharmaceutical manufacturer” means a business or entity that makes, processes, or packages prescription drugs, over-the-counter medications, or medical devices to sell in a pharmacy or other healthcare facility.
(B) “Prescription drug manufacturer” or “pharmaceutical manufacturer” includes an entity that manipulates, tests, or controls the product or process;
(30) “Prescription drug manufacturer coupon” or “pharmaceutical manufacturer coupon” means a prescription drug discount that is:(A) Utilized to reduce the cost of prescription medications in a pharmacy at the point of sale in the form of copayment reduction, discount, e-voucher, electronic voucher, or a card to help a consumer reduce the out-of-pocket costs, including without limitation a copayment and coinsurance, or otherwise lower the overall cost of prescription drugs; and(B) Sponsored or provided by a prescription drug manufacturer or pharmaceutical manufacturer usually through a vendor or an electronic claims processor;
(A) Utilized to reduce the cost of prescription medications in a pharmacy at the point of sale in the form of copayment reduction, discount, e-voucher, electronic voucher, or a card to help a consumer reduce the out-of-pocket costs, including without limitation a copayment and coinsurance, or otherwise lower the overall cost of prescription drugs; and
(B) Sponsored or provided by a prescription drug manufacturer or pharmaceutical manufacturer usually through a vendor or an electronic claims processor;
(31) (A) “Rebate” means a discount or other price concession, or a payment that is:(i) Based on utilization of a prescription drug; and(ii) Paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefits manager, pharmacy services administrative organization, or pharmacy after a claim has been processed and paid at a pharmacy.(B) “Rebate” includes without limitation incentives, disbursements, and reasonable estimates of a volume-based discount;
(A) “Rebate” means a discount or other price concession, or a payment that is:(i) Based on utilization of a prescription drug; and(ii) Paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefits manager, pharmacy services administrative organization, or pharmacy after a claim has been processed and paid at a pharmacy.
(i) Based on utilization of a prescription drug; and
(ii) Paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefits manager, pharmacy services administrative organization, or pharmacy after a claim has been processed and paid at a pharmacy.
(B) “Rebate” includes without limitation incentives, disbursements, and reasonable estimates of a volume-based discount;
(32) (A) “Self-administered prescription drug” means a pharmaceutical that when prescribed does not require assistance by a third party to administer and can be dispensed by a pharmacy or pharmacist to an enrollee for self-administration under federal and state laws and regulations.(B) “Self-administered prescription drug” does not include over-the-counter medications that do not require a prescription;
(A) “Self-administered prescription drug” means a pharmaceutical that when prescribed does not require assistance by a third party to administer and can be dispensed by a pharmacy or pharmacist to an enrollee for self-administration under federal and state laws and regulations.
(B) “Self-administered prescription drug” does not include over-the-counter medications that do not require a prescription;
(33) “Spread pricing” means the model of prescription drug pricing in which the pharmacy benefits manager charges a health benefit plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the pharmacy benefits manager directly or indirectly pays the pharmacist or pharmacy for pharmacist services;
(34) “Third party” means a person, business, or entity other than a pharmacy benefits manager that is not an enrollee or insured in a health benefit plan;
(35) “Underpayment violation” means:(A) A violation of § 23-92-506(b);(B) A violation of § 17-92-507; or(C) A fair and reasonable compensation payment violation as defined under § 23-92-506(a) and by rule of the commissioner; and
(A) A violation of § 23-92-506(b);
(B) A violation of § 17-92-507; or
(C) A fair and reasonable compensation payment violation as defined under § 23-92-506(a) and by rule of the commissioner; and
(36) “Unique combination for pharmacy claims” means a pharmacy claims bank identification number, pharmacy claims group number, pharmacy claims processor control number, or any combination of a pharmacy claims bank identification number, pharmacy claims group number, and pharmacy claims processor control number that is used by a pharmacy benefits manager to process a pharmacy claim.