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<br />TEXAS HEALTH PLANS, INC. <br /> <br />PRESCRIPTION DRUG RIDER <br />TO <br />TEXAS HEALTH PLANS, INC ( THP ) AGREEMENT <br /> <br />In consideration of the premium to be paid, this Texas Health Plans, Inc. <br />Agreement is hereby amended by the attachment thereto of this rider. <br /> <br />1. <br /> <br />DEFT NITI ONS <br /> <br />1.1 <br /> <br />"Co payment " means tne amount wh} c.n will be c.narged to the Covered <br />Person by the participating THP Pharmacy for dispensing or refilling <br />of any Prescription Order. <br /> <br />1.2 <br /> <br />"Covered Drugs" are those prescribed ÈY ~ Participating Physician and <br />which, under Federal or State law, can be dispensed only pursuant to a <br />Prescription. Order oTis a compounded prescription wnicn contains at <br />least one legend ingredient or insulin. The maximum coverage shall <br />not exceed that required for 34 consecutive days, with the following <br />exceptions: a) up to a three-month supply of oral contraceptives may <br />be dispensed for a single Copayment Charge per cycle; b) one vial of <br />insulin may be dispensed for a single Copayment Charge. <br /> <br />1.3 <br /> <br />"Covered Person" means either the Enrollee or Family Dependent, but <br />applies only while such coverage of such person under the THP contract <br />is in. effect. <br /> <br />1.4 <br /> <br />"Health Plan Drug Formulary" means generic listia.g of Prescription <br />Medications which will be dispensed as Covered Drugs through Health <br />Plan Participating Pharmacies to Covered Persons. This list includes: <br />a) the generic drug name; b) the strength; c.) the dose; and, d) the <br />trade name of the drug to which the generic drug is equivalent. In <br />addition, this will include the Drug Product Selection List which is a <br />listing of multisource generic equivalent dnlg products. These lists <br />will be subject to periodic review an.d modification by Health Plan. <br /> <br />1.5 <br /> <br />"Participating Pharmacy" means a Pharmacy which has entered into a <br />service agreement with THP to provide services to Covered Persons. <br /> <br />1.6 <br /> <br />"Physician" means any Doctor of Medicine, "M.D." or"O.O." who is duly <br />licensed and qualified under the law of jurisdiction in. which <br />treatment is received, who is authorized to prescribe the Covered <br />Drugs and who is a participating THP Physician approved by THP for <br />said purpose. <br /> <br />1.7 <br /> <br />"Prescription Medication" means a drug which can, under Fe'deral or <br />State law, be dispensed only pursuant to a Prescription Order, aT <br />which is a compounded prescription or insulin. <br /> <br />THPRX 10/87 <br /> <br />-1- <br />