Source: https://www.law.cornell.edu/cfr/text/42/423.100
Timestamp: 2017-10-22 08:59:55
Document Index: 468148514

Matched Legal Cases: ['art 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423', '§ 423']

42 CFR 423.100 - Definitions. | US Law | LII / Legal Information Institute
CFR › Title 42 › Chapter IV › Subchapter B › Part 423 › Subpart C › Section 423.100
§ 423.100 Definitions.
Alternative prescription drug coverage means coverage of Part D drugs, other than standard prescription drug coverage that meets the requirements of § 423.104(e). The term alternative prescription drug coverage must be either -
(1)Basic alternative coverage (alternative coverage that is actuarially equivalent to defined standard coverage, as determined through processes and methods established under § 423.265(d)(2)); or
(2)Enhanced alternative coverage (alternative coverage that meets the requirements of § 423.104(f)(1)).
Applicable beneficiary means an individual who, on the date of dispensing a covered Part D drug -
(6) Has a claim that -
Applicable drug means a Part D drug that is -
(i) Approved under a new drug application under section 505(b) of the Federal Food, Drug, and Cosmetic Act (FDCA); or
(i) If the PDP sponsor of the prescription drug plan or the MA organization offering the MA-PD plan uses a formulary, which is on the formulary of the prescription drug plan or MA-PD plan that the applicable beneficiary is enrolled in;
Covered Part D drug means a Part D drug that is included in a Part D plan's formulary, or treated as being included in a Part D plan's formulary as a result of a coverage determination or appeal under §§ 423.566, 423.580, and 423.600, 423.610, 423,620, and 423.630, and obtained at a network pharmacy or an out-of-network pharmacy in accordance with § 423.124.
Daily cost-sharing rate means, as applicable, the established -
Incurred costs means costs incurred by a Part D enrollee for -
(i) Covered Part D drugs that are not paid for under the Part D plan as a result of application of any annual deductible or other cost-sharing rules for covered Part D drugs prior to the Part D enrollee satisfying the out-of-pocket threshold under § 423.104(d)(5)(iii), including any price differential for which the Part D enrollee is responsible under § 423.124(b); or
(2) That are paid for -
(ii) Under State Pharmaceutical Assistance Program (as defined in § 423.464); by the Indian Health Service, an Indian tribe or tribal organization, or urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act) or under an AIDS Drug Assistance Program (as defined in part B of title XXVI of the Public Health Service); or by a manufacturer as payment for an applicable discount (as defined in § 423.2305) or under the Medicare Coverage Gap Discount Program (as defined in § 423.2305); or
Personal health savings vehicle means a vehicle through which individuals can set aside their own funds to pay for health care expenses, including covered Part D drugs, on a tax-free basis including any of the following -
Required prescription drug coverage means coverage of Part D drugs under an MA-PD plan that consists of either -
Standard prescription drug coverage means coverage of Part D drugs that meets the requirements of § 423.104(d). The term standard prescription drug coverage must be either -
(1)Defined standard coverage (standard prescription drug coverage that provides for cost-sharing as described in § 423.104(d)(2)(i)(A) and (d)(5)(i)); or
(2)Actuarially equivalent standard coverage (standard prescription drug coverage that provides for cost-sharing as described in § 423.104(d)(2)(i)(B) or cost-sharing as described in § 423.104(d)(5)(ii), or both).
Supplemental benefits means benefits offered by Part D plans, other than employer group health or waiver plans, that meet the requirements of § 423.104(f)(1)(ii).
[ 70 FR 4525, Jan. 28, 2005, as amended at 73 FR 20506, Apr. 15, 2008; 74 FR 1543, Jan. 12, 2009; 76 FR 21571, Apr. 15, 2011; 77 FR 22169, Apr. 12, 2012; 77 FR 32407, June 1, 2012; 79 FR 29962, May 23, 2014; 80 FR 7963, Feb. 12, 2015; 80 FR 25966, May 6, 2015]
42 CFR 423.578 — Exceptions Process.
42 CFR 423.2305 — Definitions.
42 CFR 423.308 — Definitions and Terminology.
42 CFR 423.2325 — Provision of Applicable Discounts.
42 CFR 423.154 — Appropriate Dispensing of Prescription Drugs in Long-Term Care Facilities Under PDPs and MA-PD Plans.
42 CFR 423.884 — Requirements for Qualified Retiree Prescription Drug Plans.