South Carolina Code > Title 38 > Chapter 71 > Article 21 – Pharmacy Benefits Managers
Current as of: 2023 | Check for updates
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Terms Used In South Carolina Code > Title 38 > Chapter 71 > Article 21 - Pharmacy Benefits Managers
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Claim: means a request from a pharmacy or pharmacist to be reimbursed for the cost of administering, filling, or refilling a prescription for a drug or for providing a medical supply or device. See South Carolina Code 38-71-2200
- Claims processing services: means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include:
(a) receiving payments for pharmacist services;
(b) making payments to pharmacists or pharmacies for pharmacist services; or
(c) both receiving and making payments. See South Carolina Code 38-71-2200 - Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Contract: A legal written agreement that becomes binding when signed.
- Conviction: A judgement of guilt against a criminal defendant.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Department: means the Department of Insurance of South Carolina. See South Carolina Code 38-1-20
- Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the department. See South Carolina Code 38-1-20
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Freedom of Information Act: A federal law that mandates that all the records created and kept by federal agencies in the executive branch of government must be open for public inspection and copying. The only exceptions are those records that fall into one of nine exempted categories listed in the statute. Source: OCC
- Health benefit plan: means any individual, blanket, or group plan, policy, or contract for health care services issued or delivered by a health care insurer in this State as defined in § 38-71-670(6) and 38-71-840(14), including the state health plan as defined in § 1-11-710. See South Carolina Code 38-71-2200
- insurance: includes annuities. See South Carolina Code 38-1-20
- Insurer: includes a corporation, fraternal organization, burial association, other association, partnership, society, order, individual, or aggregation of individuals engaging or proposing or attempting to engage as principals in any kind of insurance or surety business, including the exchanging of reciprocal or interinsurance contracts between individuals, partnerships, and corporations. See South Carolina Code 38-1-20
- License: means a document issued by the state's director or his designee authorizing a person to act as an insurance producer for the lines of authority specified in the document. See South Carolina Code 38-1-20
- Maximum Allowable Cost List: means a listing of generic drugs used by a pharmacy benefits manager to set the maximum allowable cost at which reimbursement to a pharmacy or pharmacist may be made. See South Carolina Code 38-71-2200
- Negotiate: means the act of conferring directly with or offering advice directly to a purchaser or prospective purchaser of a particular contract of insurance concerning substantive benefits, terms, or conditions of the contract, provided that the person engaged in that act either sells insurance or obtains insurance from insurers for purchasers. See South Carolina Code 38-1-20
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Other prescription drug or device services: means services other than claims processing services, provided directly or indirectly by a pharmacy benefits manager, whether in connection with or separate from claims processing services, including without limitation:
(a) negotiating rebates, discounts, or other financial incentives and arrangements with drug companies;
(b) disbursing or distributing rebates;
(c) managing or participating in incentive programs or arrangements for pharmacist services;
(d) negotiating or entering into contractual arrangements with pharmacists or pharmacies, or both;
(e) developing formularies;
(f) designing prescription benefit programs; or
(g) advertising or promoting services. See South Carolina Code 38-71-2200 - Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
- Person: means a corporation, agency, partnership, association, voluntary organization, individual, or another entity, organization, or aggregation of individuals. See South Carolina Code 38-1-20
- Pharmacist services: means products, goods, and services, or any combination of products, goods, and services, provided as a part of the practice of pharmacy. See South Carolina Code 38-71-2200
- Pharmacy benefits manager: means an entity that contracts with pharmacists or pharmacies on behalf of an insurer, third party administrator, or the South Carolina Public Employee Benefit Authority to:
(a) process claims for prescription drugs or medical supplies or provide retail network management for pharmacies or pharmacists;
(b) pay pharmacies or pharmacists for prescription drugs or medical supplies; or
(c) negotiate rebates with manufacturers for drugs paid for or procured as described in this article. See South Carolina Code 38-71-2200 - Pharmacy benefits manager affiliate: means a pharmacy or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a pharmacy benefits manager. See South Carolina Code 38-71-2200
- Policy: means a contract of insurance. See South Carolina Code 38-1-20
- Service of process: The service of writs or summonses to the appropriate party.
- Testimony: Evidence presented orally by witnesses during trials or before grand juries.
South Carolina Code > Title 38 > Chapter 71 > Article 21 – Pharmacy Benefits Managers
Current as of: 2023 | Check for updates
|
Other versions
Terms Used In South Carolina Code > Title 38 > Chapter 71 > Article 21 - Pharmacy Benefits Managers
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Claim: means a request from a pharmacy or pharmacist to be reimbursed for the cost of administering, filling, or refilling a prescription for a drug or for providing a medical supply or device. See South Carolina Code 38-71-2200 v2
- Claims processing services: means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include:
(a) receiving payments for pharmacist services;
(b) making payments to pharmacists or pharmacies for pharmacist services; or
(c) both receiving and making payments. See South Carolina Code 38-71-2200 v2 - Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Contract: A legal written agreement that becomes binding when signed.
- Conviction: A judgement of guilt against a criminal defendant.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Department: means the Department of Insurance of South Carolina. See South Carolina Code 38-1-20
- Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the department. See South Carolina Code 38-1-20
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Freedom of Information Act: A federal law that mandates that all the records created and kept by federal agencies in the executive branch of government must be open for public inspection and copying. The only exceptions are those records that fall into one of nine exempted categories listed in the statute. Source: OCC
- Health benefit plan: means any individual, blanket, or group plan, policy, or contract for health care services issued or delivered by a health care insurer in this State as defined in § 38-71-670(6) and 38-71-840(14), including the state health plan as defined in § 1-11-710. See South Carolina Code 38-71-2200 v2
- insurance: includes annuities. See South Carolina Code 38-1-20
- Insurer: includes a corporation, fraternal organization, burial association, other association, partnership, society, order, individual, or aggregation of individuals engaging or proposing or attempting to engage as principals in any kind of insurance or surety business, including the exchanging of reciprocal or interinsurance contracts between individuals, partnerships, and corporations. See South Carolina Code 38-1-20
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- License: means a document issued by the state's director or his designee authorizing a person to act as an insurance producer for the lines of authority specified in the document. See South Carolina Code 38-1-20
- Maximum Allowable Cost List: means a listing of generic drugs used by a pharmacy benefits manager to set the maximum allowable cost at which reimbursement to a pharmacy or pharmacist may be made. See South Carolina Code 38-71-2200 v2
- Negotiate: means the act of conferring directly with or offering advice directly to a purchaser or prospective purchaser of a particular contract of insurance concerning substantive benefits, terms, or conditions of the contract, provided that the person engaged in that act either sells insurance or obtains insurance from insurers for purchasers. See South Carolina Code 38-1-20
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Other prescription drug or device services: means services other than claims processing services, provided directly or indirectly by a pharmacy benefits manager, whether in connection with or separate from claims processing services, including without limitation:
(a) negotiating rebates, discounts, or other financial incentives and arrangements with drug companies;
(b) disbursing or distributing rebates;
(c) managing or participating in incentive programs or arrangements for pharmacist services;
(d) negotiating or entering into contractual arrangements with pharmacists or pharmacies, or both;
(e) developing formularies;
(f) designing prescription benefit programs; or
(g) advertising or promoting services. See South Carolina Code 38-71-2200 v2 - Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
- Person: means a corporation, agency, partnership, association, voluntary organization, individual, or another entity, organization, or aggregation of individuals. See South Carolina Code 38-1-20
- Pharmacist services: means products, goods, and services, or any combination of products, goods, and services, provided as a part of the practice of pharmacy. See South Carolina Code 38-71-2200 v2
- Pharmacy benefits manager: means an entity that contracts with pharmacists or pharmacies on behalf of an insurer, third party administrator, or the South Carolina Public Employee Benefit Authority to:
(a) process claims for prescription drugs or medical supplies or provide retail network management for pharmacies or pharmacists;
(b) pay pharmacies or pharmacists for prescription drugs or medical supplies; or
(c) negotiate rebates with manufacturers for drugs paid for or procured as described in this article. See South Carolina Code 38-71-2200 v2 - Pharmacy benefits manager affiliate: means a pharmacy or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a pharmacy benefits manager. See South Carolina Code 38-71-2200 v2
- Policy: means a contract of insurance. See South Carolina Code 38-1-20
- Service of process: The service of writs or summonses to the appropriate party.