managed care organization.
(2) The amount paid by the pharmacy benefit manager to the
pharmacy.
(3) Any differences between the amount paid in paragraph (1)
and the amount paid in paragraph (2).
(4) Other information as requested by the department.
(k) A pharmacy shall, upon request, submit the actual
acquisition cost of prescriptions dispensed to medical
assistance beneficiaries.
(m) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection:
"Adjudicated claim" means a claim that has been processed to
payment or denial.
"Entity" means a pharmacy, pharmacy benefit manager, pharmacy
services administration organization or other entity that
manages, processes, or influences the payment for or dispenses
pharmacy services to medical assistance recipients in the
managed care delivery system.
"Pharmacy benefit management" means any of the following:
(1) The procurement of prescription drugs at a negotiated
contracted rate for distribution within this Commonwealth.
(2) The administration or management of prescription drug
benefits provided by a managed care organization.
(3) The administration of pharmacy benefits, including any
of the following:
(i) Operating a mail-service pharmacy.
(ii) Processing claims.
(iii) Managing a retail pharmacy network.
(iv) Paying claims to pharmacies, including retail,
specialty or mail-order pharmacies, for prescription drugs
dispensed to medical assistance recipients receiving services in
the managed care delivery system via a retail or mail-order
pharmacy.
(v) Developing and managing a clinical formulary or
preferred drug list, utilization management or quality assurance
programs.
(vi) Rebate contracting and administration.
(vii) Managing a patient compliance, therapeutic
intervention and generic substitution program.
(viii) Operating a disease management program.
(ix) Setting pharmacy payment pricing and methodologies,
including maximum allowable cost and determining single or
multiple source drugs.
"Pharmacy benefit manager" means a business that performs
pharmacy benefit management. The term does not include a
business that holds a valid license from the Insurance
Department with accident and health authority to issue a health
insurance policy and governed under any of the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as "The
Insurance Company Law of 1921."
(2) The act of December 29, 1972 (P.L.1701, No.364), known
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