28 Tex. Admin. Code § 21.3002 - Definitions; Pharmacy Identification Cards
The following words and terms, when used in this division, have the following meanings, unless the context clearly indicates otherwise:
(1) Administrator--As
defined in Insurance Code §
4151.001(1),
for plans subject to Insurance Code Chapter 1369, Subchapter D.
(2) Drug--As defined in the Texas Pharmacy
Act, Occupations Code §
551.003.
(3) 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.
(4) Effective date--The
date that the health benefit plan's current prescription drug benefit levels
became effective, or the date the subscriber's coverage first became effective,
whichever is later.
(5) Enrollee--A
person covered by a health benefit plan.
(6) Enrollee identification card--A printed
card issued to enrollees of a health benefit plan that includes all necessary
information to allow an enrollee to access all coverage under the health
benefit plan.
(7) Health benefit
plan--As described in Insurance Code §
1369.151, including a
health benefit plan providing coverage for pharmacy benefits only, but not
those described in Insurance Code §
1369.152. This
definition includes the term, "plan," as defined in Insurance Code §
4151.001(4),
but does not include a self-funded employee welfare benefit plan exempt from
state regulation under ERISA,
29
U.S.C. §
1002(1)(A).
(8) Identification code--Any unique code used
by an issuer of a health benefit plan, administrator, or pharmacy benefit
manager that identifies and differentiates among enrollees.
(9) Issuer--Those entities described in
Insurance Code §
1369.151, but not
those excluded by Insurance Code §
1369.152.
(10) Pharmacy benefit manager--As defined in
Insurance Code §
4151.151, but does not
include a pharmacy benefit manager for a self-funded employee welfare benefit
plan exempt from state regulation under ERISA,
29
U.S.C. §
1002(1)(A).
(11) Pharmacy benefits--Coverage in a health
benefit plan for prescription drugs that are ordinarily and customarily
dispensed by a pharmacy or pharmacist licensed under the Texas Pharmacy Act,
Occupations Code §
551.001, et
seq.
(12) Standard identification
card--A printed card containing the written information required by §
21.3003(b) of
this title (relating to Standard Identification Cards).
(13) Subscriber--The individual who is the
contract holder and who is responsible for payment of premiums to the issuer of
an individual health benefit plan; or the individual who is the certificate
holder and whose employment or membership status, except for family dependency,
is the basis for eligibility for enrollment in a health benefit plan.
Notes
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