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Annual Enrollment Period (AEP) — The period between October 15 and December 7 of each year in which anyone eligible for Medicare prescription drug coverage may either switch or enroll in a Medicare Part D plan.
Brand drugs — The term for prescription drugs that are sold under a trademarked brand name.
Coinsurance — An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
Copay — An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.
Coverage gap — Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs.
Creditable coverage — Prescription drug coverage (for example, from an employer or union) that's expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.
Deductible — The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
Dual eligible — Persons who are entitled to Medicare and also eligible for Medicaid.
Emergency care — Care given for a medical emergency when you believe that your health is in serious danger.
Extra Help — A Medicare program to help people with limited income and resources pay Medicare prescription drug plan costs, like premiums, deductibles, and coinsurance.
Exclusions — Items or services that are not covered by the plan sponsor.
Formulary —A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
Generic drugs — These drugs are (usually) lower-cost alternatives to brand-name drugs; generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs; they contain the same active ingredient formula as the brand-name drug they replace; you may save money by switching from brand drugs to generic drugs.
Health Maintenance Organization (HMO) — a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. You must use the doctors, specialists, or hospitals in the plan's network of providers. The HMO may require you to get a referral from your primary care physician.
Home infusion pharmacy — A participating network pharmacy specializing in supplying members with home infusion therapy medications and supplies.
Indian Health Service, Tribal or Urban Indian Program (I/T/U) — A program in which the Indian Health Service, an agency within the Department of Health & Human Services (HHS), provides health services, including pharmacy access, to descendants of federally recognized American Indians and Alaskan natives.
Initial Enrollment Period (IEP) — A seven month enrollment period for those who are newly eligible for Medicare as a result of turning 65; the seven month period consists of the three months before, the three months after and the month of the applicant's 65th birthday (those who are under age 65 and have a disability may also be eligible to enroll).
Late enrollment penalty — The cost that may be imposed by the Federal government for those who do not enroll in a Medicare prescription drug plan during their initial enrollment period and do not have creditable coverage; the late enrollment penalty consists of 1 percent per month for every month you delay enrollment and affected enrollees will pay the penalty as long as they are in a Medicare Prescription Drug plan.
Long-term care pharmacy — A participating network pharmacy located in a long-term care facility.
Medicare Advantage (MA) — A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Mail-order — A delivery method in which you can receive your covered prescription drugs by mail; mail order is most often used for maintenance prescriptions and/or 90-day supplies of a covered prescription drug; mail order often provides savings because you can get a 90-day supply of eligible prescription drugs for two and a half copayments instead of three.
Medicare Advantage Prescription Drug Plan (MAPD) — A Medicare Advantage Plan (like an HMO or PPO) is a way to get your Medicare benefits. Unlike "Original Medicare," in which the government pays for Medicare benefits when you receive them, Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare, and Medicare pays these companies to cover your Medicare benefits.
Medicare approved amount — In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you're responsible for the difference.
Medical emergency — A sudden onset of a condition with acute symptoms requiring immediate medical care; includes conditions such as heart attacks, cardiovascular incidents, poisoning, loss of consciousness or respiration, convulsions or other acute medical conditions.
Network pharmacy — A pharmacy contracted with the plan sponsor where enrollees may fill their prescriptions; in most cases, prescriptions are covered only if they are filled at a network or preferred network pharmacy.
Non-Preferred Generic — Tier 2 medications are non-preferred generic medications and have the second-lowest copayment out of the five tiers.
Plan sponsor — The health plan, employer or union group and/or other approved agencies that have contracted with Medicare to provide prescription drug (Medicare Part D) coverage.
Preferred brand drug — Covered prescription drugs which Blue MedicareRx is able to offer with a lower copayment because of negotiated prices with the drug's manufacturer.
Preferred network pharmacy — If your plan has preferred pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred pharmacy because it has agreed with your plan to charge less.
Premium — The periodic payment to Medicare, an insurance company or a health care plan for health or prescription drug coverage.
Preventive services — Health care services to prevent illness or detect illness at an early stage when treatment is likely to work best; some examples of preventive services include Pap tests, flu shots and screening mammograms.
Primary care physician or doctor — The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.
Skilled nursing facility (SNF) care — Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility; some examples of SNF care include physical therapy or intravenous injections that can only be given by a doctor or a registered nurse.
Special Enrollment Period (SEP) — You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP.
True Out-of-Pocket Costs (TrOOP) — True out-of-pocket (TrOOP) costs are amounts you pay for covered Part D drugs that count towards your drug plan’s out-of-pocket threshold. Your yearly deductible, coinsurance or copayments, and what you pay in the coverage gap all count toward this out-of-pocket limit. The limit doesn’t include the drug plan’s premium.
Utilization management (UM) — The use of scientifically based medical guidelines to promote the most beneficial and effective usage of medications; utilization management programs include the following:.
Step therapy — A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.
Quantity limits — For safety and cost reasons, plans may limit the amount of prescription drugs they cover over a certain period of time. For example, most people who are prescribed a heartburn medication take 1 capsule per day for 4 weeks. Therefore, a plan may cover only an initial 30-day supply of the heartburn medication. If you need more, you may need your prescriber's help to provide more information to the plan.
Prior authorization — Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Your Medicare drug plan may require prior authorization for certain drugs.