Decision Team. The P&T Committee’s review may be based on consideration of, without limitation, U.S. Food and Drug Administration-approved labeling, standard medical reference compendia, or scientific studies published in peer-reviewed English-language bio-medical journals.
Prescription Drug Product A drug, Biologic (including a Biosimilar), or other product that has been approved by the U.S. Food and Drug Administration (FDA), certain products approved under the Drug Efficacy Study Implementation review, or products marketed prior to 1938 and not subject to review and that can, under federal or state law, be dispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Product includes a drug, Biologic or product that, due to its characteristics, is approved by the FDA for self-administration or administration by a non-skilled caregiver. For the purpose of benefits under the plan, this definition also includes: The following diabetic supplies: alcohol pads, swabs, wipes, Glucagon/Glucagen, injection aids, insulin pump accessories (but excluding insulin pumps), needles including pen needles, syringes, test strips, lancets, urine glucose and ketone strips; Needles and syringes for self-administered medications or Biologics covered under the plan’s Prescription Drug benefit; and Inhaler assistance devices and accessories, peak flow meters. This definition does not include any charges for mobile, web- based or other electronic applications or software, even if approved for marketing as a prescription product by the FDA.
HC-DFS852
10-16
Physician The term Physician means a licensed medical practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer drugs or to perform surgery. It will also include any other licensed medical practitioner whose services are required to be covered by law in the locality where the policy is issued if he is: operating within the scope of his license; and performing a service for which benefits are provided under this plan when performed by a Physician.
HC-DFS25
04-10
V1
Prescription Drug Charge The Prescription Drug Charge is the amount that, prior to application of the plan’s cost-share requirement(s), the plan sponsor is obligated to pay for a covered Prescription Drug Product dispensed at a Network Pharmacy, including any applicable dispensing fee and tax.
HC-DFS855
10-16
Prescription Order or Refill The lawful directive to dispense a Prescription Drug Product issued by a Physician whose scope of practice permits issuing such a directive.
HC-DFS1320
01-19
V1
Prescription Drug List A list that categorizes drugs, Biologics (including Biosimilars) or other products covered under the plan’s Prescription Drug Benefits that have been approved by the U.S. Food and Drug Administration (FDA) into coverage tiers. This list is developed by Cigna's Business Decision Team based on clinical factors communicated by the P&T Committee, and adopted by your Employer as part of the plan. The list is subject to periodic review and change, and is subject to the limitations and exclusions of the plan. You may determine to which tier a particular Prescription Drug Product has been assigned through the website shown on your ID card or by calling customer service at the telephone number on your ID card.
HC-DFS856
10-16
Preventive Care Medications The Prescription Drug Products or other medications (including over-the-counter medications) designated as payable by the plan at 100% of the cost (without application of any Deductible, Copayment or Coinsurance) as required by applicable law under any of the following: Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force. With respect to infants, children and adolescents, evidence- informed preventive care and screenings provided for in the
HC-DFS854
10-16
73
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