Glossary

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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 - The percentage of the drug cost that you are charged; for example, for a $100 prescription with 25 percent coinsurance, you would pay $25 and the plan sponsor would pay $75

Copay - A fixed amount you pay each time a prescription is filled; for example, a $5 copayment means that you pay $5 for each prescription, regardless of the cost of the prescription

Coverage gap - The period after an enrollee's covered drug costs exceed the initial coverage limit and before the enrollee's out-of-pocket expenses reach the true out-of-pocket (TrOOP) limit; during the coverage gap period, the member may receive discounts on certain drugs; the coverage gap period is commonly referred to as the “donut hole”

Creditable coverage - Drug coverage offered by other plan sponsors, such as employer groups or Medicare Advantage plans, that is equal to or greater in value than the standard Medicare prescription drug coverage

Deductible - The amount you pay before your plan sponsor begins to pay your benefits

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 for prescription drugs for people with limited income and resources to pay prescription drug program costs, such as premiums, deductibles and coinsurance

Exclusions - Items or services that are not covered by the plan sponsor

Formulary - A list of drugs that are approved for coverage by a plan sponsor and eligible to be dispensed through participating pharmacies

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)–sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (Hospital) and Part B (Medical) benefits. A MA plan offers a specific set of health benefits at the same premium and level of cost-sharing to all people with Medicare who live in the service area covered by the plan. Medicare Advantage Organizations can offer one or more Medicare Advantage plan in the same service area. A Medicare Advantage plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan.

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 that also offers Medicare Part D (prescription drug coverage).

Medicare approved amount - In original Medicare, the amount a doctor or supplier that accepts assignment can be paid; this may be less than the actual amount a doctor or supplier charges; Medicare pays part and the Medicare beneficiary is 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 - Using a preferred network pharmacy allows you to pay two and a half copayments instead of three for a 90-day supply of eligible prescription medications

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 —octorian or ephysician or doctor is 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) - The period of time in which a Medicare beneficiary may enroll in a Medicare Part D plan outside of the initial or annual enrollment periods due to a variety of circumstances; this may include losing employer group or group retiree coverage or moving from one state to another

TrOOP - TrOOP stands for true out-of-pocket costs, as incurred by the member under the Medicare Prescription Drug plan; TrOOP may consist of member deductibles, coinsurance and/or copayments and costs incurred while the member is in the coverage gap period

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 program which requires use of one or more specific drugs prior to the use of more potent dosages or higher quantities of other drugs
  • Quantity limits - A quantity maximum applied to a drug based on scientific and clinical reasoning; quantity limits are applied to the number of days supply or number of units dispensed
  • Prior authorization - A program which requires specific criteria be met before a drug is covered for a member