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North Dakota Century Code Title 26.1. Insurance § 26.1-27.1-01. Definitions

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In this chapter, unless the context otherwise requires:

1. “Covered entity” means a nonprofit hospital or a medical service corporation;  a health insurer;  a health benefit plan;  a health maintenance organization;  a health program administered by the state in the capacity of provider of health coverage;  or an employer, a labor union, or other entity organized in the state which provides health coverage to covered individuals who are employed or reside in the state.  The term does not include a self-funded plan that is exempt from state regulation pursuant to the Employee Retirement Income Security Act of 1974 [Pub. L. 93-406;  88 Stat. 829;  29 U.S.C. 1001 et seq.];  a plan issued for coverage for federal employees;  or a health plan that provides coverage only for accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care, or other limited-benefit health insurance policy or contract.

2. “Covered individual” means a member, a participant, an enrollee, a contractholder, a policyholder, or a beneficiary of a covered entity who is provided health coverage by the covered entity.  The term includes a dependent or other individual provided health coverage through a policy, contract, or plan for a covered individual.

3. “De-identified information” means information from which the name, address, telephone number, and other variables have been removed in accordance with requirements of title 45, Code of Federal Regulations, part 164, section 512, subsections (a) or (b).  1

4. “Generic drug” means a drug that is chemically equivalent to a brand name drug for which the patent has expired.

5. “Labeler” means a person that has been assigned a labeler code by the federal food and drug administration under title 21, Code of Federal Regulations, part 207, section 20, and that receives prescription drugs from a manufacturer or wholesaler and repackages those drugs for later retail sale.

6. “Payment received by the pharmacy benefits manager” means the aggregate amount of the following types of payments:

a. A rebate collected by the pharmacy benefits manager which is allocated to a covered entity;

b. An administrative fee collected from the manufacturer in consideration of an administrative service provided by the pharmacy benefits manager to the manufacturer;

c. A pharmacy network fee;  and

d. Any other fee or amount collected by the pharmacy benefits manager from a manufacturer or labeler for a drug switch program, formulary management program, mail service pharmacy, educational support, data sales related to a covered individual, or any other administrative function.

7. “Pharmacy benefits management” means the procurement of prescription drugs at a negotiated rate for dispensation within this state to covered individuals;  the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals;  or the providing of any of the following services with regard to the administration of the following pharmacy benefits:

a. Claims processing, retail network management, and payment of claims to a pharmacy for prescription drugs dispensed to a covered individual;

b. Clinical formulary development and management services;  or

c. Rebate contracting and administration.

8. “Pharmacy benefits manager” means a person that performs pharmacy benefits management.  The term includes a person acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a covered entity.  The term does not include a public self-funded pool or a private single-employer self-funded plan that provides benefits or services directly to its beneficiaries.  The term does not include a health carrier licensed under title 26.1 if the health carrier is providing pharmacy benefits management to its insureds.

9. “Rebate” means a retrospective reimbursement of a monetary amount by a manufacturer under a manufacturer's discount program with a pharmacy benefits manager for drugs dispensed to a covered individual.

10. “Utilization information” means de-identified information regarding the quantity of drug prescriptions dispensed to members of a health plan during a specified time period.

1  45 C.F.R. § 164.512.

Cite this article: - North Dakota Century Code Title 26.1. Insurance § 26.1-27.1-01. Definitions - last updated January 01, 2020 |

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