He-W 570.01 - Definitions

He-W 570.01. Definitions

(a) "Actual acquisition cost (AAC)" means actual acquisition cost as defined at 42 CFR 447.502, namely, the agency's determination of the pharmacy providers' actual prices paid to acquire drug products marketed or sold by specific manufacturers.

(b) "Compound drug" means a drug product prepared by the pharmacist using more than one ingredient.

(c) "Controlled substance" means a "controlled substance" as defined under 21 USC 802(6).

(d) "Co-payment" means the amount paid by a recipient to a NH medicaid enrolled pharmacy provider for each prescription filled.

(e) "Department" means the New Hampshire department of health and human services.

(f) "Dispensing fee" means a payment for the pharmacist's service of dispensing drugs.

(g) "Drug efficacy study implementation (DESI) drugs" means drugs found to lack substantial evidence of effectiveness as determined by the Food and Drug Administration (FDA) and also includes identical, related, or similar (IRS) drugs.

(h) "Federal upper limit (FUL)" means the maximum cost allowed by the federal government for certain multiple source drugs.

(i) "General public" means individuals purchasing drugs at the usual and customary retail price.

(j) "Generic equivalent" means an equivalent AB rated drug product that is suitable for drug interchange, approved by the FDA as safe and effective, with the same established generic name, active ingredient, strength, quantity, and dosage form as the drug product identified in the prescription.

(k) "Healthcare common procedure coding system (HCPCS)" means a uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies.

(l) "Identical, related, or similar (IRS) drugs" means a drug interchange or substitution as it applies to DESI drugs.

(m) "Legend drug" means a drug which is dispensed only with a prescription from a licensed practitioner.

(n) "Licensed practitioner" means any person who is lawfully entitled to prescribe, administer, dispense, or distribute legend drugs to patients.

(o) "Maintenance medication" means a drug prescribed for routine continuous daily therapy for at least 120 days.

(p) "Medicaid" means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(q) "National average drug acquisition cost (NADAC)" means a national price benchmark that represents the national average invoice price derived from retail community pharmacies for drug products based on invoices from wholesalers and manufacturers, and which is updated and published weekly by the Centers for Medicare and Medicaid Services (CMS) and available at https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html.

(r) "National drug code (NDC)" means the unique 11-digit code number assigned to any drug by the manufacturer identifying drug manufacturer or distributor, drug name, and package size.

(s) "New Hampshire maximum allowable cost (NHMAC)" means the maximum cost allowed by the department for certain multiple source drugs.

(t) "Non-legend drug" means a drug prescribed by a licensed practitioner which is normally purchased over the counter.

(u) "Non-preferred prescription drug" means a drug that has been determined to have an alternative drug available that is clinically equivalent and more cost effective, and which has been clinically reviewed and approved by the NH drug use review board established in He-C 5010 and has been included on the department's preferred drug list as non-preferred.

(v) "Parenteral" means drug administration other than by the mouth or rectum, such as by injection, infusion, or implantation.

(w) "Patient profile" means a record, whether paper or electronic, of each recipient's drug history.

(x) "Pharmacist" means "pharmacist" as defined in RSA 318:1, VII.

(y) "Pharmacy benefit manager (PBM)" means the representative designated by the department to administer the drug plan for the medicaid population.

(z) "Pharmacy lock-in program" means a program established to prevent recipients from obtaining excessive quantities of, or from inappropriately using, prescription drugs through multiple pharmacies.

(aa) "Preferred drug list (PDL)" means a formal published list of specific prescription drug products by brand and generic name divided into 2 separate categories as either preferred or non-preferred.

(ab) "Preferred prescription drug" means a drug that has been clinically reviewed and approved by the NH drug use review board established in He-C 5010 and has been included on the department's preferred drug list based on its proven clinical and cost effectiveness.

(ac) "Prescription" means "prescription" as defined in RSA 318:1, XVI.

(ad) "Primary pharmacy" means the sole pharmacy that is responsible for dispensing and, in accordance with Ph 706, monitoring the drug utilization of a recipient assigned to the pharmacy lock-in program.

(ae) "Prior authorization" means the process by which a prescriber seeks approval from the department, through its designated agent, to make payments for drugs which are considered to have a high potential for misuse or abuse, are high cost, or should be monitored for correct adherence to clinical protocols.

(af) "Recipient" means any individual who is eligible for and receiving medical assistance under the medicaid program.

(ag) "Title XIX" means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(ah) "Title XXI" means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(ai) "Unit dose drug" means the individually packaged dosage form of a drug.

(aj) "Usual and customary" means "usual and customary" as defined in RSA 126-A:3III(b).

(ak) "Wholesale acquisition cost (WAC)" means the drug manufacturer's list price to wholesale distributors or direct purchasers, not including prompt pay or other discounts, rebates, or reductions in price, as reported in wholesale price guides or other publications of drug or biological pricing data.

(Amended by Volume XXXVI Number 23, Filed June 9, 2016, Proposed by #11101, Effective 5/25/2016, Expires 5/25/2026. Amended by Volume XXXVII Number 15, Filed April 13, 2017, Proposed by #12140, Effective 4/1/2017, Expires 4/1/2027. Amended by Volume XXXVIII Number 23, Filed June 7, 2018, Proposed by #12529, Effective 5/22/2018, Expires 5/22/2028.)

(See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRES: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; amd by #10139, eff 7-1-12

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