N.H. Code Admin. R. Ins 2705.03 – Definitions

(a) “Carrier clinical review criteria” means written criteria that use nationally accepted standards of medical practice consistent with RSA 420-J:6 VI, and that have been adopted and made public by a health insurer, pharmacy benefits manager, or utilization review entity for determining the circumstances in which use of a particular prescription drug is appropriate.
(b) “Electronic prior authorization” (ePA) means prior authorization processes conducted through a health carrier’s web portal or any other secure electronic manner of transmission.
(c) “Health carrier” means “health carrier” as defined in RSA 420-G:2.
(d) “Health insurer” means those health insurance companies subject to this rule pursuant to Ins 2705.02(a)(1).
(e) “Health maintenance organization” means “health maintenance organization” as defined in RSA 420-B:1.
(f) “Health services corporation” means “health services corporation” as defined in RSA 420-A:1.
(g) “Pharmacy benefits manager” means a person who performs pharmacy benefits management services, including a person acting on behalf of a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management services for a covered entity. “Pharmacy benefits management” means the administration of prescription drug benefits provided by a covered entity under the terms and conditions of the contract between the pharmacy benefits manager and the covered entity and the provision of mail order pharmacy services.
(h) “Preferred provider program” means a program in which a health insurer contracts with or designates preferred providers as defined in RSA 420-C:2.
(i) “Prescribing provider” means any person who is lawfully entitled to prescribe, administer, dispense, or distribute prescription drugs to patients.
(j) “Prescription drug” means:
1. (1) A drug dispensed from a pharmacy directly to the consumer which, under federal law, is required, prior to being dispensed or delivered, to be labeled with any of the following statements:
  1. a. “Caution: federal law prohibits dispensing without prescription”;
  2. b. “Caution: federal law restricts this drug to use by or on the order of the licensed veterinarian”; or
  3. c. “RX only”; or
2. (2) A drug which is required by any applicable federal or state law or regulation to be dispensed on prescription only and that is dispensed from a pharmacy directly to the consumer.
(k) “Prior authorization” means utilization review conducted prior to a patient’s service or course of treatment.
(l) “Uniform prior authorization forms” means the forms set forth in Ins 2705.04(a) and to be used by health insurers, pharmacy benefits managers, and utilization review entities for prior authorization of prescription drugs pursuant to RSA 420-J:7-b, IV-c (b) and RSA 420-E:4-a, II. “Uniform prior authorization forms” includes both the versions of the forms that are prepopulated pursuant to Ins 2705.04(c) and those that are not prepopulated.
(m) “Utilization review entity” means any person, partnership, or corporation which provides utilization review services subject to RSA 420-E.