Vermont Statutes
Chapter 221 - Health Care Administration
§ 9471. Definitions

§ 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.
[Subdivision (2) effective until January 1, 2023; for subdivision (2) effective January 1, 2023 see below.]
(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;
(C) the State of Vermont and any agent or instrumentality of the State that offers, administers, or provides financial support to State government; and
(D) Medicaid, and any other public health care assistance program.
[Subdivision (2) effective January 1, 2023; for subdivision (2) effective until January 1, 2023 see above.]
(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.
[Subdivision (5) effective until January 1, 2023; for subdivision (5) effective anuary 1, 2023 see below.]
(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.
[Subdivision (5) effective January 1, 2023; for subdivision (5) effective until January 1, 2023 see above.]
(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.
[Subdivision (7) effective January 1, 2023.]
(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.)

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