Health and Safety Code section 1385.001
(a)
“Department” means the Department of Managed Health Care.(b)
“Director” means the Director of the Department of Managed Health Care.(c)
“Drug” has the same meaning as defined in Section 4025 of the Business and Professions Code.(d)
“Health insurer” means an entity licensed to provide health insurance, as defined in Section 106 of the Insurance Code.(e)
“Manufacturer” has the same meaning as defined in Section 4033 of the Business and Professions Code.(f)
“Payer” means a health care service plan licensed by the department or a health insurer licensed by the Department of Insurance.(g)
“Pharmacist” has the same meaning as defined in Section 4036 of the Business and Professions Code.(h)
“Pharmacy” has the same meaning as defined in Section 4037 of the Business and Professions Code.(i)
(1)“Pharmacy benefit manager” means a person, business, or other entity that, either directly or through an intermediary, affiliate, or both, acts as a price negotiator or group purchaser on behalf of a payer, or manages the prescription drug coverage provided by the payer, including, but not limited to, the processing and payment of claims for prescription drugs, the performance of drug utilization review, the processing of drug prior authorization requests, the adjudication of appeals or grievances related to prescription drug coverage, contracting with network pharmacies, or controlling the cost of covered prescription drugs.(2)
“Pharmacy benefit manager” includes an entity performing the duties specified in paragraph (1) that is under common ownership with, or control by, a payer.(3)
“Pharmacy benefit manager” does not include any of the following:(A)
An entity providing services pursuant to a contract authorized by Section 4600.2 of the Labor Code.(B)
A fully self-insured employee welfare benefit plan under the Employee Retirement Income Security Act of 1974 (Public Law 93-406), as amended (29 U.S.C. Sec. 1001 et seq.).(C)
A health care service plan licensed pursuant to this chapter or an individual employee of a health care service plan.(D)
A health insurer licensed to provide health insurance, as defined in Section 106 of the Insurance Code, or an individual employee of a health insurer.(E)
A city or county that develops or manages drug coverage programs for uninsured patients for which no reimbursement is received.(F)
An entity exclusively providing services to patients covered by Part 418 (commencing with Section 418.1) of Subchapter B of Chapter IV of Title 42 of the Code of Federal Regulations.(G)
The State Department of Health Care Services, including any contracts between the State Department of Health Care Services and another entity related to the negotiation and collection of drug or medical supply rebates.(j)
“Plan participant” means an individual who is enrolled in health care coverage provided by a payer.
Source:
Section 1385.001, https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1385.001. (updated Jun. 30, 2025; accessed Nov. 10, 2025).
