All defined terms in 958 CMR 9.00 are capitalized. As used in 958 CMR 9.00, these terms have the following meaning:

Acute Hospital. The teaching hospital of the University of Massachusetts Medical School and any hospital licensed under M.G.L. c. 111, § 51 that contains a majority of medical-surgical, pediatric, obstetric and maternity beds, as defined by the Department of Public Health.

Ambulatory Surgical Center. Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and meets the U.S. Centers for Medicare and Medicaid (CMS) requirements for participation in the Medicare program.

Center. The Center for Health Information and Analysis as established under M.G.L. c. 12C.

Commission. The Health Policy Commission established under M.G.L. c. 6D.

Commission Expenses. The amount appropriated by the General Court for the expenses of the Commission minus amounts collected from:

1. (a) filing fees;
2. (b) fees and charges generated by the Commission; and
3. (c) federal matching revenues received for these expenses or received retroactively for expenses of predecessor agencies. Commission Expenses shall include an amount equal to the cost of fringe benefits and indirect expenses, as established by the comptroller.

Division. Division of Insurance established under M.G.L. c. 26.

Fiscal Year (FY). The time period of 12 months beginning on October 1st of any calendar year and ending on September 30th of the following calendar year.

Gross Patient Service Revenue (GPSR). The total dollar amount of an Acute Hospital’s or an Ambulatory Surgical Center’s charges for services rendered in a Fiscal Year.

Payment. A check, draft or other paper instrument, an electronic fund transfer, or any order, instruction, or authorization to a financial institution to debit one account and credit another.

Pharmacy Benefit Manager. A person, business, or other entity, however organized, subject to licensure by the Division pursuant to M.G.L. c. 176Y, that directly or through a subsidiary provides pharmacy benefit services for prescription drugs and devices on behalf of a health plan sponsor, including but not limited to, a self-insurance plan, labor union or other third-party payer; provided however, that "pharmacy benefit manager" shall not include a health benefit sponsor unless otherwise specified by the Division.

Pharmacy Benefit Services. Services performed by a Pharmacy Benefit Manager, including:

1. (1) negotiating the price of prescription drugs including negotiating and contracting for direct or indirect rebates, discounts or other price concessions;
2. (2) managing any aspects of a prescription drug benefit, including, but not limited to, formulary administration, mail-order pharmacy and specialty drug pharmacy services, clinical, safety and adherence programs for pharmacy service, the processing and payment of claims for prescription drugs, arranging alternative access to or funding for prescription drugs, the performance of drug utilization review, the processing of drug prior authorization requests, the adjudication of appeals or grievances related to the prescription drug benefit, contracting with network pharmacies, controlling the cost of covered prescription drugs and managing or providing data relating to the prescription drug benefit or the provision of services related thereto;
3. (3) performance of any administrative, managerial, clinical, pricing, financial, reimbursement, data administration or reporting or billing service related to a health benefit plan's prescription drug benefit; and
4. (4) such other services as the Division may define in regulation.