Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter A - GENERAL PROVISIONS › Section 284-180-130 - Definitions

Current through Register Vol. 24-14, July 15, 2024
Except as defined in other subchapters and unless the context
				  requires otherwise, the following definitions apply throughout this
				  chapter:
(1) "Affiliate" or
				"affiliated employer" has the same meaning as the definition of affiliate or
				affiliated employer in RCW  48.200.020.
(2) "Certification" has the same meaning as
				the definition of certification in
				RCW
				 48.43.005.
(3) "Corporate umbrella" means an arrangement
				consisting of, but not limited to, subsidiaries and affiliates operating under
				common ownership or control.
(4)
				"Employee benefits programs" has the same meaning as the definition of employee
				benefits program in RCW  48.200.020.
(5) "Generally available for purchase" means
				available for purchase by multiple pharmacies within the state of Washington
				from national or regional wholesalers.
(6) "Health care benefit manager" has the
				same meaning as the definition of health care benefit manager in RCW
				 48.200.020.
(7) "Health care
				provider" or "provider" has the same meaning as the definition of health care
				provider in
				RCW
				 48.43.005.
(8) "Health care services" has the same
				meaning as the definition of health care services in
				RCW
				 48.43.005.
(9) "Health carrier" has the same meaning as
				the definition of health carrier in
				RCW
				 48.43.005.
(10) "Laboratory benefit manager" has the
				same meaning as the definition of laboratory benefit manager in RCW
				48.43.020.
(11) "Mental health
				benefit manager" has the same meaning as the definition of mental health
				benefit manager in RCW  48.200.020.
(12) "Net amount" means the invoice price
				that the pharmacy paid to the supplier for a prescription drug that it
				dispensed, plus any taxes, fees or other costs, minus the amount of all
				discounts and other cost reductions attributable to the drug.
(13) "Network" has the same meaning as the
				definition of network in RCW  48.200.020.
(14) "Oversight activities" includes all work
				done by the commissioner to ensure that the requirements of chapter 48.200 RCW
				are properly followed and in fulfilling its duties as required under chapter
				48.200 RCW.
(15) "Person" has the
				same meaning as the definition of person in RCW  48.200.020.
(16) "Pharmacy benefit manager" has the same
				meaning as the definition of pharmacy benefit manager in RCW
				 48.200.020.
(17) "Predetermined
				reimbursement cost" means maximum allowable cost, maximum allowable cost list,
				or any other benchmark price utilized by the pharmacy benefit manager,
				including the basis of the methodology and sources utilized to determine multi
				source generic drug reimbursement amounts. However, dispensing fees are not
				included in the calculation of predetermined reimbursement costs for
				multi-source generic drugs.
(18)
				"Radiology benefit manager" has the same meaning as the definition of radiology
				benefit manager in RCW  48.200.020.
(19) "Readily available for purchase" means
				manufactured supply is held in stock and available for order by more than one
				pharmacy in Washington state when such pharmacies are not under the same
				corporate umbrella.
(20)
				"Retaliate" means action, or the implied or stated threat of action, to
				decrease reimbursement or to terminate, suspend, cancel or limit a pharmacy's
				participation in a pharmacy benefit manager's provider network solely or in
				part because the pharmacy has filed or intends to file an appeal under RCW
				 48.200.280.
(21) "Unsatisfied"
				means that the network pharmacy did not receive the reimbursement that it
				requested at the first tier appeal.
(22) "Utilization review" has the same
				meaning as the definition of utilization review in
				RCW
				 48.43.005.