The following words and terms, when used in this division have
the following meanings, unless the context clearly indicates otherwise:
(1) Chronic illness--A disease, syndrome, or condition
of expected long duration, showing little change or slow progression.
(2) Contraindication--As defined in Insurance Code §1369.001(1).
(3) Disabling illness--A disease, syndrome, or condition
determined by an enrollee's health care practitioner to have caused
or have the potential to cause:
(A) a physical or mental impairment that substantially
limits, or may limit, one or more of the activities of daily living
of the enrollee including, but not limited to, eating, bathing, dressing,
grooming, routine hair and skin care, meal preparation, exercising,
toileting, and transfer and ambulation;
(B) an impairment substantially limiting an enrollee's
cognitive acuity;
(C) an impairment substantially limiting an enrollee's
ability to work, home make, or engage in leisure or educational activities;
or
(D) a condition regarded as an impairment by an enrollee's
licensed health care practitioner.
(4) Drug--As defined in the Texas Pharmacy Act, Occupations
Code §551.003.
(5) Enrollee--A person covered by a health benefit
plan.
(6) Health benefit plan--As described in Insurance
Code §1369.002, but not those described in §1369.003. This
term includes health benefit plans providing coverage for pharmacy
benefits only.
(7) Health care practitioner--An advanced practice
nurse, doctor of medicine, doctor of dentistry, physician assistant,
doctor of osteopathy, doctor of podiatry, or other licensed person
with prescriptive authority.
(8) Impairment--Any loss or abnormality of psychological,
physiological, or anatomical structure or function.
(9) Indication--As defined in Insurance Code §1369.001(3).
(10) Issuer--Those entities described in Insurance
Code §1369.002, but not those excluded by Insurance Code §1369.003.
(11) Life-threatening illness--A disease or condition
for which the likelihood of death is probable unless the course of
the disease or condition is interrupted.
(12) 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.
(13) Peer-reviewed medical literature--A published
scientific study in a journal or other publication in which original
manuscripts are published only after they have been critically reviewed
by unbiased independent experts in the same field for scientific accuracy,
validity, and reliability, and have been determined by the International
Committee of Medical Journal Editors to have met the Uniform Requirements
for Manuscripts submitted to biomedical journals. Peer-reviewed medical
literature does not include publications or supplements to publications
sponsored to a significant extent by a pharmaceutical manufacturing
company or an issuer of a health benefit plan.
(14) Standard drug reference compendia--
(A) The American Hospital Formulary Service-Drug Information;
or
(B) The United States Pharmacopoeia-Drug Information.
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