Definitions

The following definitions apply to the Plan.

Approved Disease-Management drugs – means covered drugs designated by the Plan that treat hypertension (high blood pressure), hyperlipidemia (high cholesterol), diabetes, and smoking cessation. For more information, see "Approved Disease-Management Drugs."

Approved Preventive drugs – means drugs designated by the Plan that can help keep you from developing a health condition. Preventive drugs may help you maintain your quality of life and avoid expensive treatment for illness and disease. For more information, see “Approved Preventive Drugs.”

Brand-Name Non-Preferred drugs – means brand-name drugs identified as Brand-Name Non-Preferred on the Coverage Tiers (Formulary).

Brand-Name Preferred drugs – means brand-name drugs identified as Brand-Name Preferred on the Coverage Tiers (Formulary).

These drugs, which along with generic drugs are sometimes referred to as "formulary" drugs, are identified on the Coverage Tiers (Formulary).

Coinsurance – means the percentage of eligible expenses that is your responsibility which may be altered based on "minimum" and "maximum" amounts and coupon availability. 

Combined Medical/Prescription Out-of-Pocket Limit – see "Annual Out-of-Pocket Limits" in the Medical Plan section.

Compound drugs – means medicines that are custom-made for an individual patient. Creating these drugs requires special expertise.

Copay – means the flat-dollar amount you pay as part of the eligible expenses that is your responsibility.

Coverage Tiers (Formulary) – means a document that summarizes the Plan’s coverage tiers, step-therapy (ST) requirements, prior-authorization (PA) requirements, quantity limits (QL), other limits or requirements, and/or exclusions that apply for most drugs available in the marketplace. For more information, see “Coverage Tiers (Formulary).” 

Generic drugs and brand-name drugs – the generic name of a drug is its chemical name. The brand name is the trade name under which the drug is advertised and sold. By law, generic drugs must meet the same standards as brand-name drugs for safety, purity, strength, and effectiveness.

Generic Non-Preferred drugs – means generic drugs identified as Generic Non-Preferred on the Coverage Tiers (Formulary).

Generic Preferred drugs – means generic drugs identified as Generic Preferred on the Coverage Tiers (Formulary).

Maintenance medications – means prescriptions for chronic conditions, such as diabetes, arthritis, or high blood pressure.

Narcotic-Addiction drugs – means drugs used to treat opioid or opiate addiction, such as addiction to heroin or narcotic pain relievers. Because narcotic-addiction drugs can cause physical dependence with chronic use, the Plan covers them only up to a six-month lifetime cap for the entire category. Examples include Suboxone, Subutex, buprenorphine, and methadone.

Prior authorization (PA) – means a program administered by EnvisionRxOptions that encourages appropriate and cost-effective use of prescription drugs by allowing coverage only when certain guidelines are met. Reasons for requiring prior authorization include compliance with dosing guidelines, avoiding duplicate therapies, and helping health care providers check that a drug is being used based on generally accepted medical criteria. The Coverage Tiers (Formulary) identifies drugs that require prior authorization.

Quantity limit (QL) – means a program administered by EnvisionRxOptions to limit quantities of certain drugs. These limits help your doctor and pharmacist check that your prescribed drug is used correctly and safely. The Coverage Tiers (Formulary) identifies drugs that have a quantity limit.

Specialty drugs – means complex therapies that may have special storage and handling requirements. For more information, see "Specialty Drugs."

Step therapy (ST) – means a program administered by EnvisionRxOptions to promote the appropriate use of clinically effective but lower-cost drugs first. These lower-cost drugs are FDA-approved and treat the same condition as the corresponding targeted step-therapy drugs. For more information, see “Step Therapy.”

Urgently needed care – means medical care or treatment that if substantially delayed (e.g., 15 days) could:

  • Seriously jeopardize the life or health of the covered individual or the ability for the individual to regain maximum function, or
  • Subject the covered individual (in the opinion of a physician with knowledge of the individual's medical condition) to severe pain that cannot be adequately managed without the specified care or treatment.