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Term
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Definition
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Annual Deductible
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The amount you must pay for your prescriptions, before your Medicare drug plan begins to pay. These amounts can change every year.
If "Under Review" appears, it means that the prescription drug coverage is still being discussed by Medicare and the plan.
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Approval Status
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If Medicare has approved the coverage and costs offered by the company for the year 2007. “As submitted by organization” means the company has a current contract with Medicare, but Medicare is still discussing the coverage and costs offered by the company for 2007.
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Cobrand
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Refers to the partner relationships established between Medicare Prescription Drug Plans and other organizations. Some drug plans enter into agreements with other organizations to help market their drug plans. These relationships are between the drug plan and the partner organizations and are outside of the contract with Medicare.
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Coinsurance
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The amount you may be required to pay for services after you pay any plan deductibles. In the Original Medicare Plan, this is a percentage (like 20%) of the Medicare approved amount.
You have to pay this amount after you pay the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent.
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Copayment
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In some Medicare health and prescription drug plans, the amount you pay for each medical service, like a doctor’s visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor’s visit or prescription. Copayments are also used for some hospital outpatient services in the Original Medicare Plan.
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Company Name
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Name of company that contracts with Medicare to offer a Medicare Prescription Drug Plan. (The number next to the name is for Medicare’s use only.)
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Cost Sharing
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The amount you pay for health care and/or prescriptions. This amount can include copayments, coinsurance, and/or deductibles.
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Coverage Gap
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Medicare drug plans may have a "coverage gap," which is sometimes called the "donut hole." A coverage gap means that after you and your plan have spent a certain amount of money for covered drugs (no more than $2,510), you have to pay out-of-pocket all costs for your drugs while you are in the "gap." The most you have to pay out-of-pocket in the coverage gap is $3,216.25. This amount doesn’t include your plan’s monthly premium that you must continue to pay even while you are in the coverage gap. Once you’ve reached your plan’s out-of-pocket limit, you will have "catastrophic coverage." This means that you only pay a coinsurance amount (like 5% of the drug cost) or a copayment (like $2.15 or $5.35 for each prescription) for the rest of the calendar year.
Note: If you get extra help paying your drug costs, you won’t have a coverage gap. However, you will probably have to pay a small copayment or coinsurance amount.
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Deductible
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The amount you must pay for health care or prescriptions, before the Medicare drug plan begins to pay. These amounts can change every year.
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Demonstration/Pilot Program
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Special projects that test improvements in Medicare coverage, payment, and quality of care. Some follow Medicare Advantage rules, but others don’t. Demonstrations are usually for a specific group of people and/or are offered only in specific areas. There are also pilot programs for people with multiple chronic illnesses designed to reduce health risks, improve quality of life, and provide savings.
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Employer or Union Retiree Plans
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Health plans that give health coverage to employees, former employees, and their families. These plans are offered to people through their (or a spouse’s) current or former employer or employee organization.
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Enhanced Alternative Plan
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Enhanced Alternative Plans can offer a more comprehensive level of coverage, with lower cost-sharing and/or additional coverage of certain drugs excluded from the standard level of coverage and basic alternative coverage. Premiums may be higher for these plans, but they offer more coverage.
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Favorites
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Your "favorites" are plans that you’re interested in. When you’re trying to decide which plan to join, you can create a list of plans you’re interested in so that you can return to the Medicare Prescription Drug Plan Finder later and still be able to see those plans. To add or remove plans from your list of "favorites", click the "Add" or "Remove" buttons on the right side of screen under the "favorites" column.
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Formulary
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A list of drugs covered by a plan
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Generic Drug
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A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
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Health Maintenance Organization (HMO)
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A type of Medicare Health Plan that is available in most areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs may be lower than in the Original Medicare Plan.
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If I Qualify for Extra Help, will My Full Premium be Covered?
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If $0 appears under the premium column, it means that the extra help you are receiving will cover the premium for that plan. If an amount of $1 or greater appears under the premium column, it means you will have to pay part of the premium because the extra help won’t cover all of it. You would be responsible for paying this monthly amount if you choose to enroll in that plan.
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Medicaid
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A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
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Medicare Advantage Plan
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Health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program.
With Medicare Advantage Plans: - You generally get all your Medicare-covered health care through that plan.
- Coverage can include prescription drug coverage.
- You may get extra benefits, such as coverage for vision, hearing, dental, and/or health and wellness programs.
- You may have lower out-of-pocket costs than the Original Medicare Plan.
- You may have to use the plan’s doctors and hospitals to get services.
You don’t need to buy a Medigap policy.
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Medicare Cost Plan
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A Medicare Cost Plan is a type of HMO. These plans may work in much the same way, and have some of the same rules, as Medicare Advantage Plans. In a Medicare Cost Plan, if you go to a non-network provider, the services are covered under the Original Medicare Plan. You would pay the Medicare Part A and Part B coinsurance and deductibles.
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Medicare Health Plan
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A plan offered by a private company that contracts with Medicare to provide you with your Medicare Part A and Part B benefits, and in most cases, Part D prescription drug benefits. Medicare Health Plans include Medicare Advantage Plans (including HMO, PPO, or Private Fee-for-Service Plans); Medicare Cost Plans; PACE plans; Special Needs Plans; and Demonstrations/Pilot Programs.
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Medicare Medical Savings Account(MSA)Plan
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A type of Medicare Advantage Plan. Medical Savings Account (MSA) Plans have two parts. The first part is a high-deductible Medicare Advantage MSA Health Plan. This health plan won’t begin to pay covered costs until you have met the annual deductible, which varies by plan. The second part is a Medical Savings Account into which Medicare deposits money that you may use to pay health care costs.
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Medicare Prescription Drug Plan
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A stand-alone drug plan, offered by insurers and other private companies to people with Medicare who receive benefits through the Original Medicare Plan; through a Medicare Private Fee-for-Service Plan that doesn’t offer prescription drug coverage; or who have a Medicare Cost Plan, or Medicare Medical Savings Account Plan. Medicare Advantage Plans may also offer qualified prescription drug coverage that must follow the same rules as Medicare Prescription Drug Plan.
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Medicare Savings Program
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Medicaid programs that help pay some or all Medicare premiums and deductibles.
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Medicare Special Needs Plan
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A special type of Medicare Advantage Plan that provides all Medicare Part A and Part B health care and services to people who can benefit the most from things like special care for chronic illnesses, care management of multiple diseases, and focused care management. These plans may limit membership to people - in certain institutions (like a nursing home),
- eligible for both Medicare and Medicaid, or
with certain chronic or disabling conditions.
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Monthly Premium
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The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage. In a few cases, a note will say “Under Review” instead of a premium amount. This means Medicare and the company are still discussing the amount.
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Non-preferred pharmacy
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A network pharmacy that offers covered drugs to plan members at higher out-of-pocket costs than what the member would pay at a preferred network pharmacy.
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Original Medicare Plan
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A fee-for-service health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
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PACE (Programs of All-inclusive Care for the Elderly)
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PACE combines medical, social, and long-term care services for frail people who live and get health care in the community. They are a joint Medicare and Medicaid option in some states. To be eligible, you must: - Be 55 years old, or older,
- Live in the service area of the PACE program,
- Be certified as eligible for nursing home care by the appropriate state agency , and
- Be able to live safely in the community.
The goal of PACE is to help people stay independent and live in their community as long as possible, while getting high quality care they need.
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Part A (Hospital Insurance)
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The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
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Part B (Medical Insurance)
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Medicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Part A.
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Plan Name
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The name of the plan offered by the company that contracts with Medicare.
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Preferred Pharmacy
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A network pharmacy that offers covered drugs to plan members at lower out-of-pocket costs than what the member would pay at a non-preferred network pharmacy.
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Preferred Provider Organization
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A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
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Prior Authorization
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Prior approval from an insurance plan before you get care or fill a prescription. In many instances, your doctor or health care provider must first contact the plan and show there is a medically-necessary reason why you must use that particular drug for it to be covered.
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Private Fee-for-Service Plan
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A type of Medicare Health Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn’t cover.
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Qualified Medicare Beneficiary (QMB)
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A Medicaid program for people with Medicare who need help in paying for Medicare services. The person with Medicare must have Medicare Part A and limited income and resources. For those who qualify, the Medicaid program pays Medicare Part A and Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.
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Quantity Limitation
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For safety and cost reasons, plans may limit the quantity of drugs that they cover over a certain period of time.
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Specified Low - Income Medicare Beneficiary (SLMB)
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A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.
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Step Therapy
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In some cases, plans require you to first try one drug before they will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, a plan may require your doctor to prescribe Drug A first. If Drug A does not work for you, then the plan will cover Drug B.
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Tiers
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Drugs on a formulary are often organized into different drug “tiers,” or groups of different drug types. Your cost depends on which drug tier your drug is in.
For example, a plan may form tiers this way: - Tier 1 – Generic drugs.
- Tier 2 – Preferred brand-name drugs.
- Tier 3– Non-preferred brand name drugs.
Contact the plan to learn more about its specific tier structure.
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