Mississippi Administrative Code › Title 30 - Professions and Occupations › Part 3001 - MISSISSIPPI PHARMACY PRACTICE REGULATIONS › Article XLV - PHARMACY BENEFIT MANAGER

Current through June 25, 2024
In addition to all other applicable sections of the
				Mississippi Code of 1972, ARTICLE XLV of the Mississippi Board of Pharmacy
				Regulation pertains specifically to Pharmacy Benefit Managers.
1. DEFINITIONS
A. "Board" means the State Board of
			 Pharmacy.
B. "Commissioner" means
			 the Mississippi Commissioner of Insurance.
C. "Day" means a calendar day, unless
			 otherwise defined or limited.
D.
			 "Electronic claim" means the transmission of data for purposes of payment of
			 covered prescription drugs, other products and supplies, and pharmacist
			 services in an electronic data format specified by a pharmacy benefit manager
			 and approved by the department.
E.
			 "Electronic adjudication" means the process of electronically receiving,
			 reviewing and accepting or rejecting an electronic claim.
F. "Enrollee" means an individual who has
			 been enrolled in a pharmacy benefit management plan.
G. "Health insurance plan" means benefits
			 consisting of prescription drugs, other products and supplies, and pharmacist
			 services provided directly, through insurance or reimbursement, or otherwise
			 and including items and services paid for as prescription drugs, other products
			 and supplies, and pharmacist services under any hospital or medical service
			 policy or certificate, hospital or medical service plan contract, preferred
			 provider organization agreement, or health maintenance organization contract
			 offered by a health insurance issuer, unless preempted as an employee benefit
			 plan under the Employee Retirement Income Security Act of 1974. However,
			 "health insurance coverage" shall not include benefits due under the workers
			 compensation laws of this or any other state.
H. "Pharmacy benefit manager" means a
			 business that administers the prescription drug/device portion of pharmacy
			 benefit management plans or health insurance plans on behalf of plan sponsors,
			 insurance companies, unions and health maintenance organizations. For purposes
			 of Sections
			 73-21-151
			 through
			 73-21-159,
			 a "pharmacy benefit manager" shall not include an insurance company that
			 provides an integrated health benefit plan and that does not separately
			 contract for pharmacy benefit management services. The pharmacy benefit manager
			 of the Mississippi State and School Employees Health Insurance Plan or the
			 Mississippi Division of Medicaid or its contractors when performing services
			 for the Division of Medicaid shall not be subject to Sections
			 73-21-151
			 through
			 73-21-159
			 because of those activities, but, if they are conducting business as a pharmacy
			 benefit manager other than with those agencies, they shall be subject to
			 Sections
			 73-21-151
			 through
			 73-21-159
			 for those activities only.
I.
			 "Pharmacy benefit management plan" means an arrangement for the delivery of
			 pharmaceutical services in which a pharmacy benefit manager undertakes to
			 administer the payment or reimbursement of any of the costs of pharmacist's
			 services for an enrollee on a prepaid or insured basis which (i) contains one
			 or more incentive arrangements intended to influence the cost or level of
			 pharmaceutical services between the plan sponsor and one or more pharmacies
			 with respect to the delivery of pharmacist's services; and (ii) requires or
			 creates benefit payment differential incentives for enrollees to use under
			 contract with the pharmacy benefit manager. A pharmacy benefit management plan
			 does not mean any employee welfare benefit plan if preempted by the Employee
			 Retirement Income Security Act of 1974, which is self-insured or self-funded,
			 the Mississippi State and School Employees Health Insurance Plan or the
			 programs operated by the Mississippi Division of Medicaid.
J. "Pharmacist", "pharmacist services" and
			 "pharmacy" or "pharmacies" shall have the same definitions as provided in
			 Section
			 73-21-73.
K. "Uniform claim form" means a form
			 prescribed by rule by the State Board of Pharmacy, provided however that, for
			 purposes of Sections
			 73-21-151
			 through
			 73-21-159,
			 the board shall adopt the same definition or rule where the State Department of
			 Insurance has adopted a rule covering the same type of claim. The board may
			 modify the terminology of the rule and form when necessary to comply with the
			 provisions of Sections
			 73-21-151
			 through
			 73-21-159.
L. "Plan sponsors" means the employers,
			 insurance companies, unions and health maintenance organizations that contract
			 with a pharmacy benefit manager for delivery of prescription
			 services.