The following words and terms, when used in §§21.3020-21.3023
of this subchapter (relating to prescription drug formulary benefits), shall
have the following meanings, unless the context clearly indicates otherwise:
(1) Adverse determination--A determination upon utilization
review that the health care services furnished or proposed to be furnished
to an enrollee are not medically necessary or not appropriate.
(2) Contracted benefit level--The copayment amount or coinsurance
percentage established at the beginning of the current plan year and set forth
in the coverage documentation.
(3) Coverage documentation--A policy, certificate of coverage,
evidence of coverage, enrollee handbook, or a plan document distributed by
an issuer, or its delegated entity, to an enrollee or to the master contract
holder, for distribution to enrollees.
(4) Delegated entity--An entity, which by itself or through
one or more entities, including but not limited to third-party administrators
and pharmacy benefit managers, as those terms are defined in Insurance Code
Article 21.07-6, which provides reimbursement for covered services or undertakes
to arrange for or provide benefits or services to an enrollee under a group
health benefit plan, and which performs on behalf of the issuer of a group
health benefit plan, any function regulated by §§21.3020 - 21.3023
of this subchapter.
(5) Drug formulary--A list of drugs for which a health benefit
plan provides coverage, approves payment, or encourages or offers incentives
for physicians or other health care providers to prescribe.
(6) Enrollee--As defined in Insurance Code Article 21.52J.
(7) Group health benefit plan--As described in Insurance Code
Article 21.52J. This term includes group health benefit plans providing coverage
for pharmacy benefits only.
(8) Issuer--Those entities identified in Insurance Code Article
21.52J, Sec. 2(a)(1)-(8).
(9) Multi-tier formulary--A drug formulary with benefit levels
in addition to generic and brand name prescription drug benefit levels.
(10) Plain language--As prescribed in §3.602 of this title
(relating to Plain Language Requirements).
(11) Plan year--A 365-day period that begins on the date the
group health benefit plan's coverage commences, or a period of one full calendar
year as defined in the group health benefit plan's coverage documentation.
(12) Prescription drug--As defined in Insurance Code Article
21.52J.
(13) Renewal date--For each group health benefit plan, the
earlier of the date specified in the coverage documentation for renewal or
the policy anniversary date. In determining the renewal date for association
or multiple employer trust group health benefit plans, issuers may use the
date specified for renewal or the policy anniversary date of either the master
contract, plan document, or certificate of coverage of each group in the association
or trust. Issuers shall use the same method of determining renewal dates for
all group health benefit plans.
|
