Participant or Plan Participant: an individual who is enrolled in the Plan and is eligible to receive health care services for which payment may be sought under the terms of this Plan Document.
Participating Pharmacy: a pharmacy that has a contractual relationship with the Pharmacy Benefit Manager to provide prescription drugs to Plan participants.
Participating Provider: a covered provider that has a contractual relationship with the Network to deliver covered services and supplies to participants.
PERS: the Public Employees’ Retirement System of Mississippi.
Pharmacy Benefit Manager: the organization under contract with the State and School Employees Health Insurance Management Board to administer the prescription drug program. The pharmacy benefit manager for the Plan is Catalyst Rx.
Physician: A Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) who is legally qualified and licensed to practice medicine at the time and place service is rendered. A Doctor of Dental Surgery (D.D.S.), Doctor of Surgical Chiropody (D.S.C.), Doctor of Podiatry (D.P.M. of Pod. D.), Optometrist (O.D.), Chiropractor (D.C.), Certified Registered Nurse Anesthetist (CRNA), Physician Assistant (PA), or Nurse Practitioner (N.P.), when duly licensed and practicing within the scope of his license, is deemed to be a physician for purposes of this Plan Document.
Plan: the self-insured Plan administered by the State and School Employees Health Insurance Management Board consisting of the Mississippi State and School Employees’ Life and Health Insurance Plan as defined in § 25-15-1 et seq. of the Mississippi Code.
Plan Document: the statement of terms and conditions of the Plan as adopted by the Plan Sponsor.
Plan Sponsor: the State and School Employees Health Insurance Management Board, acting administratively through the Department of Finance and Administration, Office of Insurance.
Pre-existing Condition: any condition for which medical advice, diagnosis, care, treatment, consultation, or a prescription drug was recommended or received within six (6) months prior to the Plan participant’s effective date with the Plan. Medical condition or condition means any physical or mental condition resulting from illness, injury, or congenital malformation. However, genetic information is not a condition. Benefits are not provided under this Plan for any pre- existing condition until coverage in this Plan has been in effect for a period of 12 consecutive months (or 18 months for late entrants). The pre-existing condition exclusion does not apply to pregnancy. The pre-existing condition exclusion does not apply to newborn or newly adopted children enrolled within 31 days of birth or adoption. The exclusion period will be reduced by the amount of prior creditable coverage that the participant has when coverage becomes effective.
Prescription Drug: drugs that under Federal Law may be dispensed only by written prescription and that the Food and Drug Administration has approved for general use. Prescription drugs must be dispensed by a licensed pharmacist upon the prescription order from a licensed prescriber,