N.D. Cent. Code § 26.1-27.1-01 Definitions
26.1-27.1-01. Definitions
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 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 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 policies or
contracts that do not include prescription drug coverage.
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).
4. "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.
5. "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 or a rebate aggregator
which is allocated to a covered entity, or retained by the pharmacy benefits
manager;
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, pharmacy price concessions, and any other financial
payment made by a pharmacy to a pharmacy benefits manager; 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.
6. "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, pharmacy 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.
7. "Pharmacy benefits manager" means a person who performs pharmacy benefits
management, as a third party, under a contract or other financial arrangement with a
covered entity. The term does not include a health benefit plan that manages or directs
its own pharmacy benefits.
8. "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.
9. "Utilization information" means de-identified information regarding the quantity of drug
prescriptions dispensed to members of a health plan during a specified time period.