The following words and terms when used in this division have
the following meanings, unless the context clearly indicates otherwise:
(1) Adverse determination--As defined in Insurance
Code §4201.002.
(2) Allowed amount--The amount that the applicable
health benefit plan issuer allows as reimbursement for a health care
service, supply, or prescription drug, including reimbursement amounts
for which a patient is responsible due to deductibles, copayments,
or coinsurance.
(3) Contracted benefit level--The copayment amount
or coinsurance percentage established at the beginning of the current
plan year and described in the coverage documentation.
(4) 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.
(5) Delegated entity--An entity or an association of
entities, including third-party administrators, as they are defined
in Insurance Code §4151.001(1), and pharmacy benefit managers,
as they are defined in Insurance Code §4151.151, that provides
reimbursement for covered services or undertakes to arrange for or
provide benefits or services to an enrollee under a health benefit
plan, and that performs on behalf of the issuer of a health benefit
plan, any function regulated by this division.
(6) Direct electronic link--A hyperlink that, when
clicked, delivers a user directly to the applicable website destination.
(7) Drug--As defined in the Texas Pharmacy Act, Occupations
Code §551.003.
(8) Drug formulary or 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. This term does not include a health benefit
plan that:
(A) offers coverage for any FDA approved drug;
(B) does not include a tiered structure;
(C) does not contain a list of drugs; and
(D) does not include utilization requirements for particular
drugs or classes of drugs.
(9) Enrollee--As defined in Insurance Code §1369.051(2).
(10) Health benefit plan--An insurance policy or evidence
of coverage as described in Insurance Code §1369.052, but not
those described in Insurance Code §1369.053, that provides coverage
for a discrete package of benefits, paired with specific cost-sharing
parameters. This term includes health benefit plans providing coverage
for pharmacy benefits only.
(11) Issuer--Those entities described in Insurance
Code §1369.052, but not those excluded by Insurance Code §1369.053.
(12) Multitier formulary--A drug formulary with benefit
levels in addition to generic and brand-name prescription drug benefit
levels.
(13) Off-label drug use--The use of a drug that is
approved by the Food and Drug Administration for the treatment of
one medical condition but is used to treat another medical condition,
or at different dosage forms, dosage regimens, populations, or other
parameters not mentioned in the approved labeling.
(14) Plain language--As prescribed in §3.602 of
this title (relating to Plain Language Requirements).
(15) Plan year--A 365-day period that begins on the
date the health benefit plan's coverage commences, or a period of
one full calendar year as defined in the health benefit plan's coverage
documentation.
(16) Prescription drug--As defined in Insurance Code §1369.051(4).
(17) Renewal date--For each 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 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 must use the same
method of determining renewal dates for all health benefit plans.
(18) Summary health plan document--A document summarizing
the coverage provided under a health benefit plan, including:
(A) a summary of benefits and coverage, as required
under 42 U.S.C. §300gg-15 and 45 CFR §147.200; and
(B) a disclosure of terms and conditions of a policy,
as required under §3.3705(b) of this title (relating to Nature
of Communications with Insureds; Readability, Mandatory Disclosure
Requirements, and Plan Designations), or an evidence of coverage,
as required under §11.1600(b) of this title (relating to Information
to Prospective and Current Contract Holders and Enrollees).
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