Okla. Stat. tit. 59, § 59-357v2: Definitions

A. As used in Sections 357 through 360 of this title:

1. “Covered entity” means a nonprofit hospital or medical

service organization, for-profit hospital or medical service

organization, insurer, health benefit plan, health maintenance

organization, health program administered by the state in the

capacity of providing health coverage, or an employer, labor union,

or other group of persons that provides health coverage to persons

in this state. This term does not include a health benefit plan

that provides coverage only for accidental injury, specified

disease, hospital indemnity, disability income, or other limited

benefit health insurance policies and contracts that do not include

prescription drug coverage;

2. “Covered individual” means a member, participant, enrollee,

contract holder or policy holder or beneficiary of a covered entity

who is provided health coverage by the covered entity. A covered

individual includes any dependent or other person provided health

coverage through a policy, contract or plan for a covered

individual;

3. “Department” means the Insurance Department;

4. “Effective rate contracting” means any agreement or

arrangement between a pharmacy or contracting agent acting on behalf

of a pharmacy and a pharmacy benefits manager for pharmaceuticals

based on the effective rate of payment rather than a predetermined

fixed price or fixed discount percentage;

5. “Maximum allowable cost”, “MAC”, or “MAC list” means the

list of drug products delineating the maximum per-unit reimbursement

for multiple-source prescription drugs, medical product, or device;

6. “Multisource drug product reimbursement” (reimbursement)

means the total amount paid to a pharmacy inclusive of any reduction

in payment to the pharmacy, excluding prescription dispense fees and

professional fees;

7. “Office” means the Office of the Attorney General;

8. “Pharmacy benefits management” means a service provided to

covered entities to facilitate the provision of prescription drug

benefits to covered individuals within the state, including

negotiating pricing and other terms with drug manufacturers and

providers. Pharmacy benefits management may include any or all of

the following services:

a. claims processing, retail network management and

payment of claims to pharmacies for prescription drugs

dispensed to covered individuals,

b. clinical formulary development and management

services, or

c. rebate contracting and administration;

9. “Pharmacy benefits manager” or “PBM” means a person,

business, or other entity that performs pharmacy benefits

management. The term shall include a person or entity acting on

behalf of a PBM in a contractual or employment relationship in the

performance of pharmacy benefits management for a managed care

company, nonprofit hospital, medical service organization, insurance

company, third-party payor, or a health program administered by an

agency or department of this state;

10. “Plan sponsor” means the employers, insurance companies,

unions and health maintenance organizations or any other entity

responsible for establishing, maintaining, or administering a health

benefit plan on behalf of covered individuals; and

11. “Provider” means a pharmacy licensed by the State Board of

Pharmacy, or an agent or representative of a pharmacy, including,

but not limited to, the pharmacy’s contracting agent, which

dispenses prescription drugs or devices to covered individuals.

B. Nothing in the definition of pharmacy benefits management or

pharmacy benefits manager in the Patient’s Right to Pharmacy Choice

Act, Pharmacy Audit Integrity Act, or Sections 357 through 360 of

this title shall deem an employer a “pharmacy benefits manager” of

its own self-funded health benefit plan, except, to the extent

ch

dispenses prescription drugs or devices to covered individuals.

B. Nothing in the definition of pharmacy benefits management or

pharmacy benefits manager in the Patient’s Right to Pharmacy Choice

Act, Pharmacy Audit Integrity Act, or Sections 357 through 360 of

this title shall deem an employer a “pharmacy benefits manager” of

its own self-funded health benefit plan, except, to the extent

permitted by applicable law, where the employer, without the

utilization of a third party and unrelated to the employer’s own

pharmacy:

a. negotiates directly with drug manufacturers,

b. processes claims on behalf of its members, or

c. manages its own retail network of pharmacies.