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 in the Covered Medication Search.

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 Covered Medication Search.

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.

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

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 in the Covered Medication Search.

Generic Preferred drugs – means generic drugs identified as Generic Preferred in the Covered Medication Search.

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

Prior authorization (PA) – means a program administered by Elixir (formerly known as 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. Covered Medication Search identifies drugs that require prior authorization.

Quantity limit (QL) – means a program administered by Elixir to limit quantities of certain drugs. These limits help your doctor and pharmacist check that your prescribed drug is used correctly and safely. Covered Medication Search 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 Elixir 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 member's life, health, or ability to regain maximum function, or
  • Subject the member (in the opinion of a physician with knowledge of the member’s medical condition) to severe pain that cannot be adequately managed without the specified care or treatment.