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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 - This is the term for prescription drugs that are sold under a trademarked brand name.
Coinsurance - This is the percentage of the drug cost that you pay for. For example, for a $100 prescription with 25 percent coinsurance, you would pay $25 and the plan sponsor would pay $75.
Copay - This is a fixed amount that 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 - It is the period after an enrollee's drug spending exceeds the initial coverage limit and before the enrollee's out-of-pocket expenses reach the TrOOP limit. During this period, the member may receive discounts on certain drugs.
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 to the standard Medicare prescription drug coverage.
Deductible - This is 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.
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.
Federal Poverty Level (FPL) - (Officially: the HHS Federal Poverty Guidelines). The level set by the Federal government, which states how much money an individual or families of varying sizes need to live a basic existence. Many Federal and state programs use the FPL to determine eligibility for programs. The Census Bureau publishes the Federal poverty statistics, including the FPL, annually.
Generic drugs - These drugs are lower-cost alternatives to brand drugs. These drugs are rated by the FDA to be as safe and effective as brand drugs. They contain the same active ingredient formula as the brand drug they replace. You usually can save money by switching from brand drugs to generic drugs.
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, provides health services, including pharmacy access, to descendants of federally recognized American Indians and Alaskan natives.
Initial Enrollment Period (IEP) - This is 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 during their initial enrollment period. The late enrollment penalty consists of 1% per month for every month you delay enrollment.
Long-Term Care Pharmacy - A participating network pharmacy located in a Long-Term Care facility.
Mail-Order - This is the term for prescriptions you get filled at a pharmacy that typically mails you a 90-day supply of one 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 (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.
Medicare Advantage Prescription Drug Plan (MAPD) - a Medicare Advantage plan that also offers Medicare Part D (prescription drug coverage).
Medical Emergency - A sudden onset of a condition with acute symptoms requiring immediate medical care and includes such conditions as heart attacks, cardiovascular accidents, poisoning, loss of consciousness or respiration, convulsions or other such acute medical conditions.
Network Pharmacy - A network pharmacy is a pharmacy contracted with the plan sponsor where enrollees fill their prescriptions. In most cases, prescriptions are covered only if they are filled at a network or preferred network pharmacy.
Non-preferred Generics - See model EOC
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 - Drugs which Blue MedicareRx is able to offer with a lower copayment because of negotiated prices with the drug's maker.
Preferred Network Pharmacy - 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.
Preferred Provider Organization (PPO) - a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less when you use health care providers in the plan’s network. You can use providers from outside of the network, but may have to pay more.
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.
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 very limited circumstances.
TrOOP - TrOOP stands for "true out-of-pocket" costs, as incurred by the member under the plan. TrOOP may consist of member deductibles, coinsurance and/or copayments, and costs incurred while member is in the Coverage Gap Stage.
Urgently Needed Care - Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than the Original Medicare Plan. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.
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 of, or higher quantities of other drugs.
Quantity Limits - A quantity maximum applied to a medication 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.