Texas § IN.1369.051 - DEFINITIONS

§ IN.1369.051. DEFINITIONS

DEFINITIONS. In this subchapter: (1) "Clinical practice guideline" means a statement systematically developed by a multidisciplinary panel of experts composed of physicians and, as necessary, other health care providers to assist a patient or health care provider in making a decision about appropriate health care for a specific clinical circumstance or condition. (1-a) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by a health benefit plan issuer, utilization review organization, or independent review organization to determine the medical necessity and appropriateness or the experimental or investigational nature of a health care service or prescription drug. (1-b) "Drug formulary" means a list of drugs: (A) for which a health benefit plan provides coverage; (B) for which a health benefit plan issuer approves payment; or (C) that a health benefit plan issuer encourages or offers incentives for physicians to prescribe. (2) "Enrollee" means an individual who is covered under a health benefit plan, including a covered dependent. (3) "Physician" means a person licensed as a physician by the Texas State Board of Medical Examiners. (4) "Prescription drug" has the meaning assigned by Section 551.003 , Occupations Code. (5) "Step therapy protocol" means a protocol that requires an enrollee to use a prescription drug or sequence of prescription drugs other than the drug that the enrollee's physician recommends for the enrollee's treatment before the health benefit plan provides coverage for the recommended drug. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405 ), Sec. 1, eff. September 1, 2011. Acts 2017, 85th Leg., R.S., Ch. 103 (S.B. 680 ), Sec. 1, eff. September 1, 2017.