California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.4 - Standard Prescription Drug Formulary Template › Section 2218.81 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this article, the terms defined below have the
					 following meanings.
(a) "Coverage
				  document" means a health insurance policy, evidence of coverage, certificate of
				  coverage, schedule of benefits, or any other contract for health
				  coverage.
(b) "Dosage form" means
				  the physical form in which a prescription drug is produced and dispensed, such
				  as a tablet, a capsule, or an injectable.
(c) "Established name" means the official,
				  nonproprietary name for a drug, as defined in section
				  111225
				  of the Health and Safety Code, which must appear on the label pursuant to
				  section
				  111355
				  of the Health and Safety Code.
(d)
				  "Exception request" means the process by which an insured requests and gains
				  access to coverage for a clinically appropriate non-formulary drug pursuant to
				  subdivision (i) of section
				  10123.191
				  of the Insurance Code.
(e) "Exigent
				  circumstances" means when an insured is suffering from a health condition that
				  may seriously jeopardize the insured's life, health, or ability to regain
				  maximum function, or when an insured is undergoing a current course of
				  treatment using a non-formulary drug.
(f) "Formulary" means the complete list of
				  prescription drugs preferred for use and eligible for coverage under a health
				  insurance product, and includes all drugs covered under the outpatient
				  prescription drug benefit of the product.
(g) "Health insurance" has the same meaning
				  as defined in section
				  106 of the
				  Insurance Code.
(h) "Non-formulary
				  drug" means any prescription drug for which an insured's copayment or
				  out-of-pocket costs are different than the copayment for a formulary
				  prescription drug, except as otherwise provided by law or regulation and when a
				  prescription drug that is not listed on the formulary is covered pursuant to an
				  exception request.
(i) "Plan"
				  means, with respect to a product, the pairing of the health benefits under a
				  product with a particular cost sharing structure, provider network, and service
				  area.
(j) "Prescription drug" or
				  "drug" means a drug, as that term is defined in section
				  109925
				  of the Health and Safety Code, which is limited to prescription use by law. As
				  used in this article, the term "prescription drug" or "drug" also includes:
(1) Disposable devices that are medically
				  necessary for the administration of a covered prescription drug, such as
				  spacers and inhalers for the administration of aerosol outpatient prescription
				  drugs;
(2) Syringes for
				  self-injectable prescription drugs that are not dispensed in pre-filled
				  syringes;
(3) Drugs, devices, and
				  FDA-approved products covered under the outpatient prescription drug benefit of
				  the product pursuant to sections
				  10112.2,
				  10123.196,
				  and
				  10176.61 of
				  the Insurance Code, including any over-the-counter drugs, devices, and
				  FDA-approved products that must be covered pursuant to those sections;
				  and
(4) At the option of a health
				  insurer, any vaccines or other health benefits covered under the outpatient
				  prescription drug benefit of the product.