Code of the District of Columbia

§ 48–831.02. Definitions.

For the purposes of this chapter, the term:

(1) “AccessRx” means the District of Columbia AccessRx program established by § 48-831.03.

(2) “Average wholesale price” means the wholesale price charged for a specific commodity that is assigned by the drug wholesaler and is listed in a nationally recognized drug pricing registry that is updated daily and charged to the retail pharmacy.

(3) “Basic component of AccessRx” includes the provision of drugs and medications for cardiac conditions and high blood pressure, diabetes, arthritis, anticoagulation, hyperlipidemia, osteoporosis, chronic obstructive pulmonary disease and asthma, incontinence, thyroid diseases, glaucoma, Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis, and other conditions approved by the Department. The term “basic component of AccessRx” shall also include the provision of over-the-counter medications that are prescribed by a health care provider and approved as cost-effective by the Department.

(4)(A) “Covered entity” means:

(i) Any hospital or medical service organization, insurer, health coverage plan, or health maintenance organization licensed in the District that contracts with another entity to provide prescription drug benefits for its customers or clients;

(ii) Any health program administered by the Department or the District in its capacity as provider of health coverage; or

(iii) Any employer, labor union, or other group of persons organized in the District that contracts with another entity to provide prescription drug benefits for its employees or members who are employed or reside in the District of Columbia.

(B) The term “covered entity” does not include a health plan that provides coverage only for accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care, or other limited benefit health insurance policies and contracts.

(5) “Covered individual” means a member, participant, enrollee, contract holder, policy holder, or beneficiary of a covered entity who is provided a prescription drug benefit by the covered entity. The term “covered individual” includes a dependent or other person provided a prescription drug benefit through a policy, contract, or plan for a covered individual.

(6) “Department” means the Department of Health.

(7) “Director” means the Director of the Department of Health.

(8) “District” means the District of Columbia.

(9) “Generic drug” means a chemically equivalent copy of a brand-name drug with an expired patent.

(10) “Initial discounted price” for a drug means the price the Department pays D.C. Medicaid participating retail pharmacies for that drug for District of Columbia Medicaid recipients.

(11) “Labeler” means an entity or person that receives prescription drugs from a manufacturer or wholesaler and repackages those drugs for later retail sale and that has a labeler code from the federal Food and Drug Administration under 21 C.F.R. § 207.20.

(12) “Manufacturer” means a manufacturer of prescription drugs and includes a subsidiary or affiliate of a manufacturer.

(13) “Marketing” means advertising and promotional activities, including, but not limited to, the activities described in § 48-833.03.

(14) “National Drug Code registration number” means the number registered for a drug pursuant to the listing system established by the United States Food and Drug Administration under section 510 of the Federal Food, Drug, and Cosmetic Act, approved October 10, 1962 (76 Stat. 794; 21 U.S.C. § 360).

(15) “Participating retail pharmacy” or “retail pharmacy” means a retail pharmacy located in the District, or another business licensed to dispense prescription drugs in the District, that participates in the program.

(16) “Pharmacy benefits management” means a service provided to covered entities to facilitate the provision of prescription drug benefits to covered individuals for dispensation within the District of Columbia, including negotiating pricing and other terms with drug manufacturers and retails pharmacies. “Pharmacy benefits management” may include any or all of the following:

(A) Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals for dispensation within the District of Columbia;

(B) Clinical formulary development and management services;

(C) Rebate contracting and administration;

(D) Certain patient compliance, therapeutic intervention, and generic substitution programs; and

(E) Disease management programs.

(17) “Pharmacy benefits manager” means an entity that performs pharmacy benefits management. The term “pharmacy benefits manager” includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a covered entity.

(18) “Qualified resident” means a resident of the District who is eligible for the AccessRx program pursuant to this subchapter.

(19) “Secondary discounted price” means the initial discounted price minus any further discounts paid for out of the AccessRx Fund.

(20) “Supplemental component of AccessRx” includes all prescription drugs and medications provided under the D.C. Medicaid program excluding those provided pursuant to the basic component of AccessRx.