118 Out - of - Network Provider A Provider that does not have an agreement or contract with us, or our subcontractor(s) to give services to Members under this Plan. You will often get a lower level of benefits when you use Out - of - Network Providers. Out - of - Pocket Limit The most you pay in Copayments, Deductibles, and Coinsurance during a Benefit Period for Covered Services. The Out - of - Pocket limit does not include your Fees, amounts over the Maximum Allowed Amount, or charges for health care that your Plan doesn’t cover. Please see the “Schedule of Benefits” for details. Partial Hospitalization Program Structured, multidisciplinary treatment for Mental Health and Substance Use Disorders, including nursing care and active individual, group and family treatment for Members who require more care than is available in an Intensive Outpatient Program. Pharmacy and Therapeutics (P&T) Process The P&T process is a two - step process used to make determinations that will help you access quality, low - cost medicines within your Plan. This process first uses an independent P&T committee of pharmacists and physicians that evaluate the clinical evidence of each product under review. During the second step of the process, a committee composed of members with various expertise combines the clinical review with an in - depth analysis of market dynamics, Member impact and financial value to make determination s about the formulary. Our programs may include, but are not limited to, Drug utilization programs, prior authorization criteria, therapeutic conversion programs, cross - branded initiatives, and Drug profiling initiatives. Physician (Doctor) Includes the following when licensed by law: • Doctor of Medicine (M.D.) legally entitled to practice medicine and perform surgery, • Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O., • Doctor of Chiropractic (D.C.), legally licensed to perform the duties of a chiropracto r, • Doctor of Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and • Doctor of Dental Medicine (D.D.M.), Doctor of Dental Surgery (D.D.S.), legally entitled to provide dental services. Optometrists, Clinical Psychologists (PhD), and surgical chiropodists are also Providers when legally licensed and giving Covered Services within the scope of their licenses. Plan The arrangement chosen by the Plan Sponsor to fund and provide for delivery of the Employer’s health benefits. Plan Administrator The person or entity named by the Plan Sponsor to manage the Plan and answer questions about Plan details. The Plan Administrator is not the Claims Administrator.