Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 2 - IDENTIFICATION CARDS › Section 21.3002 - Definitions; Pharmacy Identification Cards

Current through Reg. 49, No. 28; July 12, 2024
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.