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Appeal
If you disagree with our decision to deny your coverage, you can ask us to reconsider it. We call this an appeal. You can appeal our denial for health care services or prescription drug coverage.
Beneficiary
This is a person who has health care insurance through a Medicare or Medicaid program.
Brand-name drug
A prescription drug that is made and sold by the company that originally researched and developed the drug. A brand-name drug has the same active ingredients and formula as its generic version. Generally, other companies cannot make generic versions of brand-name drugs until after the patent on the brand-name drug has expired.
Case management programs
These programs help people who need extra assistance and help. Case managers help to coordinate care.
Catastrophic coverage stage
This is the drug coverage stage that happens after you get out of the coverage gap (donut hole). With catastrophic coverage, you only pay coinsurance or a copay for covered drugs for the rest of the year.
Centers for Medicare & Medicaid Services (CMS)
CMS is a federal agency that runs the Medicare program. It also works with states to run the Medicaid program.
Coinsurance
Amount you may have to pay for your share of services. Coinsurance is usually a percentage (for example, 20 percent).
Complaint
The formal name for “making a complaint” is “filing a grievance.” You can use the complaint process for certain types of problems you may have with your plan’s service. These include issues with quality of care, wait times and customer service. Also see “Grievance.”
Copay / Copayment
Amount you may have to pay for your share of services. Copays are usually a set amount (for example, $10 for a prescription drug or $20 for a doctor’s visit).
Cost sharing
What you pay for care. Examples of cost-sharing can include a deductible, copayment or coinsurance.
Coverage determination
This is the first decision your Medicare drug plan (not the pharmacy) makes about your benefits. This can be a decision about if your drug is covered, if you met the plan’s requirements to cover the drug, or how much you pay for the drug. You’ll also get a coverage determination decision if you ask your plan to make an exception to its rules to cover your drug.
Coverage gap
Also called the “donut hole”. The coverage gap is the period that begins after you and your drug plan together have spent a certain amount for covered drugs and have reached the initial coverage limit. When you’re in the coverage gap, you will pay no more than 25% of the cost for your plan’s covered prescription drugs, which may be more than your usual copay or coinsurance. The coverage gap ends when you have spent enough to qualify for catastrophic coverage.
Deductible
This is the amount some plans require you to pay for covered services before the plan starts to pay.
Disenroll
This means to end your membership in our plan. Disenrollment may be voluntary (your choice) or involuntary (not your choice).
Donut Hole
Also called the “coverage gap”. The donut hole is the period that begins after you and your drug plan together have spent a certain amount for covered drugs. When you’re in the donut hole, you will pay no more than 25% of the cost of your plans covered prescription drugs, which may be more than your usual copay or coinsurance. The donut hole ends when you have spent enough to qualify for catastrophic coverage.
Drug tier
This is a group of drugs on a formulary (drug list). Each group or tier requires a different level of payment. You might see the groups listed as generic drugs, brand-name drugs or preferred brand-name drugs. Higher tiers usually have higher cost sharing. For example, a drug on Tier 2 generally will cost more than a drug on Tier 1.
Enrollee
This is a member of our Medicare plan.
Evidence of Coverage (EOC)
The EOC gives you detailed information on your plan’s coverage, costs and your rights and responsibilities as a plan member.
Exception
This is a type of coverage determination. If approved, an exception may let you get a drug that’s not on your plan’s formulary, or drug list (a formulary exception). Or, you could get a non-preferred drug at the lower, preferred, cost-sharing level (a tier exception). You may also ask for an exception if your plan requires you to try another drug before giving you the drug you’re requesting (called step therapy). Another example is if the plan limits the quantity or dosage of the drug you’re requesting.
Extra Help
This is a program that helps people with limited income and resources pay their Medicare prescription drug plan costs, such as premiums, deductibles and coinsurance. The Extra Help program is run by the Social Security Administration.
Formulary
This is a list of prescription drugs your plan covers. It’s sometimes called a drug list.
Generic drug
A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same ingredient(s) as the brand-name drug. Generally, a “generic” drug works the same as a brand-name drug and usually costs less.
Grievance
A type of complaint about the quality of your care.
Group health plan
We also call this group coverage. This is a health plan that an employer or other group may offer to people like retirees.
Health Maintenance Organization (HMO)
A health maintenance organization is a type of medical plan. With most HMO plans, you can only go to doctors, other health care providers or hospitals in the plan’s network except in urgent or emergency situations. You may need to get a referral from your primary care doctor.
Initial coverage limit
This is a set amount of drug costs. They include what you pay, plus what your plan pays. When you reach the initial coverage limit, you enter the coverage gap (donut hole), and the terms of your benefits change.
Initial coverage stage
This is the stage before your total drug costs have reached the initial coverage limit. Total drug costs include what you have paid and what your plan has paid.
Initial Enrollment Period (IEP)
This period lasts for seven months. It centers on the event that qualifies you for Medicare. For most people, that event is your 65th birthday.
In network
This means we have a contract with a doctor or other health care provider. We negotiate reduced rates with network providers to help you save money. Network providers won't bill you for the difference between their standard rate and their contracted rate. All you pay is your coinsurance or copay, along with any deductible.
Late enrollment penalty
If you go without creditable coverage (coverage that’s at least as good as Original Medicare) for at least 63 days in a row, your monthly premium for Medicare drug coverage will include an extra amount. This amount is your late enrollment penalty. You’ll pay this extra amount for as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive Extra Help from Medicare to pay your prescription drug plan costs, you won’t pay a late enrollment penalty.
Low-income subsidy (LIS)
See "Extra Help.”
MA Plan
This type of Medicare Advantage Plan doesn’t cover prescription drugs.
MAPD Plan
This type of Medicare Advantage Plan includes Medicare prescription drug coverage.
Maximum out-of-pocket amount
This is the most you’ll pay in a year for certain health services. See your Evidence of Coverage for more information, including the maximum amount you’ll pay.
Medicaid (Medical Assistance)
A program that provides health coverage to specific individuals including low-income adults, children, elderly adults and people with disabilities. It’s funded jointly by states and the federal government and administered by states according to federal requirements.
Medicare
This is a federal health insurance program for people age 65 or older. Some people under age 65 also may be eligible for Medicare. People with Medicare can get their health coverage through original Medicare, a Medicare Cost Plan, a PACE (Program of All-Inclusive Care for the Elderly) plan or a Medicare Advantage Plan.
Medicare Part D
Prescription drug coverage. You can get Part D through a Medicare Advantage plan that offers prescription drugs. Or through a separate Prescription Drug plan.
Medigap or Medicare Supplement
These are two names for Medicare Supplement insurance. Private insurance companies sell it to fill “gaps” in Original Medicare. Medigap (Medicare Supplement) policies only work together with Original Medicare. You can’t have a Medicare Advantage Plan and a Medigap policy too.
Member
A member is a person with Medicare who is eligible for covered services and has enrolled in our plan. The Centers for Medicare & Medicaid Services has also confirmed their enrollment.
Network
This is a group of health care providers. It includes doctors, dentists and hospitals. A health care provider in a network signs a contract with a health plan to provide services. Usually, a network provider provides these services at a special rate. With some health plans, you get more coverage when you get care from network providers.
Network pharmacy
This is a pharmacy that has a contract with our plan. In most cases, we only cover your prescriptions if you fill them at a network pharmacy.
Network provider
This is a provider that has an agreement with our plan. The plan pays a network provider based on the agreement. We also call network providers plan providers.
Optional supplemental benefits
These are benefits that Medicare doesn’t cover. You can purchase them for an additional premium.
Organization determination (coverage decision)
This is a decision about whether we cover items or services or how much you have to pay for covered items or services.
Out-of-network pharmacy
This is a pharmacy that doesn’t have a contract with us. We don’t cover most drugs you get from out-of-network pharmacies, unless certain conditions apply.
Out-of-network provider or out-of-network facility
These are providers or facilities that don’t have a contract with us to deliver covered services to you.
Point-of-Service option (POS)
This type of health plan lets you see network providers. You can also see providers outside the network. In many POS plans, if you use referrals and see a primary care physician (PCP), you get more coverage. You may also pay less for care. You can still get care from a provider who isn’t a PCP, but you might pay more for that care.
Preferred Provider Organization (PPO ESA)
A PPO plan with an extended service area (ESA) gives you the flexibility to see any provider, in or out of network, at the same cost, according to the costs listed on your plan benefits summary. They just have to be licensed, eligible to receive Medicare payments and willing to accept your plan.
Premium
This is the amount you pay for coverage. If you get coverage from an employer or group health plan, the costs might be shared between you and the employer.
Primary Care Physician (PCP) or Primary Care Doctor
A PCP is a doctor who is part of a health plan's network, and sometimes called your main doctor. Your PCP is your main contact for care. A PCP gives you referrals for other care. They coordinate the care you get from specialists or other care facilities. Some health plans require you to choose a PCP.
Prior authorization
Some services or prescription drugs require your doctor and the plan to approve them before you get care or fill a prescription. The approval tells you if the plan covers the service or prescription. Check with your plan to see which drugs or services need prior authorization. Prior authorization is also called precertification, certification and authorization. In Texas, this approval is known as pre-service utilization review and is not verification as defined by Texas law.
Provider
This is a doctor, hospital, pharmacy or other licensed professional or facility that provides medical services.
Quantity Limits (QL)
With most drugs, we can only approve a certain amount at once for safety, quality or usage reasons.
Referral
A referral is a type of preapproval from your primary care doctor to see a specialist. When your doctor issues a referral, they share the reason for the recommendation with the specialist. They also help coordinate your visit so, you get the proper care.
Special Enrollment Period (SEP)
This is also called a special election period. If you have a Medicare plan, it’s a time when you can change your benefits because something in your life changes. Examples are moving out of a plan’s service area or being able to get Medicaid.
Special Needs Plan (SNP)
This is a type of Medicare Advantage Plan. It provides more focused health care for specific groups of people, such as those who:
Have both Medicare and Medicaid
Live in a nursing home
Have certain chronic medical conditions
Step therapy
Step therapy requires you to try another drug to treat your medical condition. We see if it works before we cover the drug that your doctor may have originally prescribed.