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- Administrative Services Agreement
- The Administrative Services Agreement entered into between the Employer and EHIM.
- Average Wholesale Price or "AWP"
- The list price for a pharmaceutical, as established by a pharmaceutical database supplier of EHIM's choosing including, but not limited to, First Data Bank, Redbook, or Bluebook
- Brand Name Drug
- A drug that is protected by a patent and marketed under a trade name (whether or not such name is registered or trademarked).
- Child
- The meaning given to such term in the Employer Health Plan. If no such definition exists, "Child" means a Participant's natural child, step-child, legally adopted child or foster child, including those born after the execution of this Plan, provided such individual is dependent upon the Participant for support and maintenance and has not yet attained age 19.
- COBRA
- The Consolidated Omnibus Budget Reconciliation Act (Pub.L. 99-272), A federal law which requires most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of heatlh coverage at group rates in certain instances where coverage under the plan would otherwise end.
- Copayment
- The portion of the charge for a prescription that must be paid to the Pharmacy by the Covered Person at the time the prescription is dispensed.
- Covered Expenses
- The costs incurred with respect to prescription services for which benefits are provided hereunder.
- Covered Person
- Any Participant or Dependent while such Participant or Dependent is covered under the Employer Health Plan. With reference to a Dependent, "Covered" shall mean that the Participant is covered under the Employer Health Plan with respect to such Dependent.
- Dependent
- A person who is designated as such in the Employer Health Plan. In the event no such designations exist, a "Dependent" or "Eligible Dependent" means a legal spouse or an unmarried Child of a Participant, other than:
- a legally separated spouse; or
- a Child who has reached age 19, provided that, a Child shall remain eligible until the end of the Plan Year in which age 19 is attained; or
- a spouse or Child on active duty in any military force of any country; or
- a spouse or Child who is an Employee eligible to participate in this Plan, whether or not enrolled in this Plan.
- Eligible Dependent
- A person who is designated as such in the Employer Health Plan. In the event no such designations exist, a "Dependent" or "Eligible Dependent" means a legal spouse or an unmarried Child of a Participant, other than:
- a legally separated spouse; or
- a Child who has reached age 19, provided that, a Child shall remain eligible until the end of the Plan Year in which age 19 is attained; or
- a spouse or Child on active duty in any military force of any country; or
- a spouse or Child who is an Employee eligible to participate in this Plan, whether or not enrolled in this Plan.
- Dispense as Written or "DAW"
- A prescription in which the physician has forbidden the use of a Generic drug rather than the indicated Brand Name drug.
- Effective Date
- The first date a plan, such as a prescription benefit plan, begins processing claims for the Plan Sponsor
- Employee
- Any individual in the employ or formerly in the employ of the Employer at a specific date and time.
- Employer
- The entity to which an employee is employed
- ERISA
- The Employee Retirement Income Security Act of 1974 which regulates employee retirement and welfare plans(Pub.L. 93-406)
- Full-Time Employee
- Any Employee who is regularly scheduled to work at least the number of hours per week for the Employer as required by the Employer Health Plan in order for an Employee to become a Participant in such Employer Health Plan
- Generic Drug
- A drug that is no longer protected by a patent.
- Initial Eligibility Date
- The first day on which an Employee may become a Participant in the Employer Health Plan.
- Leave of Absence
- Any period of absence, with or without pay, approved by the Employer during which a Participant does not perform duties for the Employer but is still treated as having a current employment relationship with the Employer
- Maintenance Drug
- A prescription medication that EHIM’s drug program allows to be dispensed in quantities that exceed a 34-day supply.
- Maximum Allowable Cost (MAC)
- The MAC sets the maximum reimbursement for commonly dispensed drugs when there are generic products available.
- Non-Participating Pharmacy
- A Pharmacy that is not a Participating Pharmacy
- Over the counter (OTC)
- Drugs that do not require a prescription.
- Participant
- An Employee who has attained the Initial Eligibility Date and who is enrolled in the Employer Health Plan
- Participating Pharmacy
- A properly licensed Pharmacy that has entered into a Pharmacy Services Agreement with EHIM, pursuant to which the Pharmacy agrees to provide pharmacy services to Participants and Dependents at a price agreed-upon in advance by the Pharmacy and EHIM.
- Pharmacy
- A place where drugs and medicines are dispensed.
- Pharmacy Network
- The group of pharmacies with which EHIM has contracted to receive discounted prices
- Prescription Drug
- Insulin or a drug or biological that requires a prescription of a licensed physician for its use by an individual.
- Rebate
- A financial incentive offered to a PBM by a drug manufacturer to promote one specific drug over another. EHIM does not accept rebates, substaintially lowering medication costs for members and insuring that the patient's needs, rather than drug company dollars, drive the decision to prescribe on drug over another.
- Utilization Review
- Process in which EHIM reviews patterns of drug usage including distribution across employees and types of drugs
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