Louisiana § RS 22:1863

§ RS 22:1863.

SUBPART C-1. PHARMACY BENEFIT MANAGERS§1863. Definitions

            As used in this Subpart, the following definitions apply:

            (1) "Drug Shortage List" means a list of drug products posted on the United States Food and Drug Administration drug shortage website.

            (2) "Effective rate pricing" means any payment reduction for pharmacist or pharmacy services by a pharmacy benefit manager under a reconciliation process for direct or indirect remuneration fees, a brand or generic effective rate of reimbursement, or any other reduction or aggregate reduction of payment.

            (3) "Health benefit plan", "health plan", "plan", "benefit", or "health insurance coverage" means services consisting of medical care provided directly through insurance, reimbursement, or other means, and including items and services paid for as medical care under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization contract, or health maintenance organization contract offered by a health insurance issuer. However, excepted benefits are not included as a "health benefit plan".

            (4) "Health insurance issuer" means any entity that offers health insurance coverage through a plan, policy, or certificate of insurance subject to state law that regulates the business of insurance. "Health insurance issuer" shall also include a health maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Code.

            (5) "Local pharmacy" means a pharmacy as defined in the North American Industry Classsification System (NAICS) Code 456110, which is domiciled in Louisiana and has fewer than ten retail outlets under its corporate umbrella.

            (6) "Maximum Allowable Cost List" means a listing of the National Drug Code used by a pharmacy benefit manager setting the maximum allowable cost on which reimbursement to a pharmacy or pharmacist may be based. "Maximum Allowable Cost List" shall include any term that a pharmacy benefit manager or a healthcare insurer may use to establish reimbursement rates for generic and multi-source brand drugs to a pharmacist or pharmacy for pharmacist services.

            (7) "NDC" means the National Drug Code, a numerical identifier assigned to all prescription drugs.

            (8) "Pharmacist" means a licensed pharmacist as defined in R.S. 22:1852.

            (9) "Pharmacist services" means products, goods, or services provided as a part of the practice of pharmacy as defined in R.S. 22:1852.

            (10) "Pharmacy" means any appropriately licensed place where prescription drugs are dispensed as defined in R.S. 22:1852.

            (11) "Pharmacy benefit manager" has the same meaning as the term defined in R.S. 22:1641 and includes any person, either directly or indirectly, that provides one or more pharmacy benefit management services on behalf of an insurer or health plan, and any agent, contractor, intermediary, affiliate, subsidiary, or related entity of such person who facilitates, provides, directs, or oversees the provision of the pharmacy benefit management services.

            (12) "Pharmacy benefits plan" or "pharmacy benefits program" means a plan or program that pays for, reimburses, covers the cost of, or otherwise provides for pharmacist services to individuals who reside in or are employed in Louisiana.

            (13) "Rebates" means all rebates, discounts, and other price concessions, based on utilization of a prescription drug and paid by the manufacturer or other party other than an enrollee, directly or indirectly, to the pharmacy benefit manager after the claim has been adjudicated at the pharmacy. Rebates shall include a reasonable estimate, as determined by the commissioner, of any volume-based discount or other discounts.

            (14) "Specialty drug" means a drug that meets all of the following criteria:

            (a) The drug is used to treat and is prescribed for a person with a complex, chronic, or rare medical condition that is progressive, can be debilitating or fatal if left untreated or undertreated, or for which there is no known cure.

            (b) The drug is not routinely stocked at a majority of pharmacies within this state.

            (c) The drug has special handling, storage, inventory, or distribution requirements.

            (d) Patients receiving the drug require complex education and treatment maintenance, such as complex dosing, intensive monitoring, or clinical oversight.

            (15) "Spread pricing" means any amount charged or claimed by a pharmacy benefit manager for a prescription drug that exceeds the amount paid by the pharmacy benefit manager to the pharmacist or pharmacy for the dispensing of the prescription drug, minus a pharmacy benefit management fee.

            Acts 2014, No. 391, §1; Acts 2018, No. 597, §1, eff. Jan. 1, 2019; Acts 2019, No. 124, §1, eff. July 1, 2020; Acts 2025, No. 474, §1, eff. June 20, 2025.