28 Tex. Admin. Code § 21.3020 - Definitions; Prescription Drug Formulary
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).
Notes
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