AARP - peter vogel



AARP |AARP (formerly known as the American Association of Retired Persons) - membership organization leading positive social change and delivering value to people age 50 and over through information, advocacy and service. | |

|Actuarially Equivalent |Drug coverage equal to or greater than the standard Part D benefit. Actuarially equivalent has a different meaning when |

| |discussing group retiree. |

|Advertising |Advertising materials are intended to attract or appeal to a plan sponsor consumer. Advertising materials contain less |

| |detail than other marketing materials. Examples include: television, radio ads, print ads, billboards and direct mail. |

|Annual Election Period – AEP – |November 15th through December 31st annually. The period when consumers and members can make new plan choices. Consumers |

|(MAPD & Part D) |may elect to join a Medicare Advantage (MA) or Prescription Drug (Part D) Plan for the first time. Members can change or |

| |add Part D, change MA Plans or return to Original Medicare. Elections made during this period will become effective January|

| |1st of the following year. |

|Annual Notice of Change – ANOC – |Notification to active members of premium, benefits and cost-sharing changes for the next calendar year. Also, the name |

|(MAPD & Part D) |used to describe the process of generating the plan information for the next calendar year notifications. |

|Appeal – (Part D, including Part D |Also known as a re-determination. Any of the procedures that deal with the review of adverse coverage determinations made |

|benefits offered as part of an MAPD|by the Part D Plan sponsor on the benefits under a Part D Plan the member believes he or she is entitled to receive. |

|Plan) |Appeals must be addressed within seven calendar days (72 hours for medically urgent issues). Appeals may be segmented into |

| |one of two categories: |

| |•         Clinical Appeals: The appeal for coverage is associated with the provision of member health information and |

| |accompanying clinical justification for coverage (e.g. Medical Necessity). |

| |•         Administrative Appeals: The appeal for coverage is not associated with the provision of accompanying clinical |

| |justification for coverage (e.g. Vacation Overrides). |

|ASI |AARP Services, Inc. |

|Assets – (Part D, including Part D |Property the government may review when Medicare consumers apply for assistance. For help with Part D Plan’s costs, the |

|benefits offered as part of an MAPD|government counts cash or any property that can be turned into cash within 20 days. This includes checking and savings |

|Plan) |accounts, certificates of deposit, IRAs and 401K’s, stocks, bonds and similar items. It does not include consumers’ primary|

| |home or certain property related to burial expenses, depending on the state. |

|Auto-Enrolled – (MAPD & Part D) |Consumers who are dually eligible for both Medicare and Medicaid and have been automatically enrolled in a Medicare Part D |

| |Plan without actively selecting a plan. Also called Auto-assigned. |

|Beneficiary |One who receives Medicare. Referred to as "consumers" throughout this document. One who is entitled to Medicare Part A and |

| |enrolled in Part B. |

|  Catastrophic Coverage – (MAPD & |Once members reach the plan’s out-of-pocket limit during the coverage gap, they automatically get “catastrophic coverage.” |

|Part D) |Catastrophic coverage assures that once they have spent up to the plan’s out-of-pocket limit for covered drugs, they only |

| |pay a small coinsurance amount or a copayment for the rest of the year. |

| |Note: If a member gets “extra help” paying their drug costs, they won’t have a coverage gap and will pay a small or no |

| |copayment once they reach catastrophic coverage. |

|Centers for Medicare & Medicaid |CMS is the Federal government agency that oversees the Medicare and Medicaid Programs by establishing regulations and |

|Services – CMS |guidance for health care providers, assessing quality of care in facilities and services, and ensuring that both programs |

| |are run properly by contractors and state agencies. |

|Clinical Parameters – (MAPD & Part |Clinical boundaries for choosing medications within established therapeutic categories for the formulary; often indicates |

|D) |how many therapy options are needed within the therapy category to ensure the formulary is clinically sound. Clinical |

| |parameters are often represented by one of three classifications: Essential (Must Have on the Formulary as Offers Unique |

| |Clinical Advantages); Non-Essential (Optional addition to the Formulary similar to Other Formulary Alternatives); or |

| |Inappropriate (Potentially less safe or obsolete compared to Other Formulary Alternatives). |

|Closed Benefit – (MAPD & Part D) |Benefit excludes medications not housed within the benefit; if a closed benefit applies to a tier structure, only those |

| |medications assigned to one of the tiers are covered. Closed benefits can have exceptions processes into place to support |

| |appeals to the benefit for coverage of excluded medications. Also known as a Closed Formulary. |

|Co-Branding |The relationship between two or more separate legal entities, one of which is an organization that sponsors a medical plan.|

|Coinsurance |A kind of cost-sharing where consumers pay the cost of a benefit on a percentage basis. |

|Consumer |A term when used refers to the customer, beneficiary, lead, member or prospect for all products. |

|Coordinated Care – (MAPD) |In Part C, health care plans that coordinate a consumer's care by the physicians and hospitals visited. These plans may |

| |have some restrictions on the physicians and hospitals used for care. These plans are also referred to as “managed care” |

| |plans. PFFS and MSA Plans are not coordinated care plans. |

|Copayment |An amount the member may be required to pay as their share of the cost for a medical service or supply, like a physician’s |

| |visit or a prescription. A copayment is usually a set amount, rather than a percentage. |

|Cost–sharing – (MAPD & Part D) |The amounts that a member has to pay when drugs or services are received. The most common types of cost-sharing are |

| |coinsurance and copayments. |

|Coverage Determination – (Part D, |Decision to cover (or not cover) therapies within the plan’s benefit design that are associated with utilization management|

|including Part D benefits offered |programs. Part D coverage decisions must be addressed and communicated within 72 hours for Standard Coverage Determination |

|as part of an MAPD Plan) |and 24 hours for Expedited Coverage Determination of the request being received. |

|Coverage Gap – (MAPD & Part D) |Most Medicare drug plans have a coverage gap. This means that after the member and plan have spent a certain amount of |

| |money for covered drugs, the member has to pay all costs out-of-pocket for their drugs up to a limit. The member’s yearly |

| |deductible, coinsurance or copayments, and what they pay in the coverage gap all count toward this out-of-pocket limit. The|

| |limit does not include the drug plan’s premium. There are plans that offer some coverage in the gap. However, plans with |

| |coverage in the gap may charge a higher monthly premium. Check with the plan first, to see if the consumer’s drugs would be|

| |covered in the gap. |

|Creditable Coverage – (MAPD & Part |Prescription medication coverage, for a plan other than a Part D Plan, which meets certain Medicare standards. For |

|D) |consumers currently enrolled in a drug plan that gives prescription medication coverage, their plan will tell them if it |

| |meets the Medicare standards for creditable coverage. See late-enrollment penalty. |

|Creditable Coverage – |Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition waiting period |

|(Medigap/Medicare Supplement Plans)|under a Medigap Plan. |

| |Note: This is not the same as creditable prescription medication coverage. |

|Critical Access Hospital – (PFFS) |A small facility that gives limited outpatient and inpatient services to consumers in rural areas. |

|Deductible |The amount a consumer or member must pay for health care or prescriptions, before Original Medicare, their prescription |

| |drug plan, or other insurance begins to pay. |

|Deemed Provider – (PFFS) |A Medicare-eligible provider who agrees to accept the Plan’s terms and conditions of payment for a specific member visit by|

| |virtue of the fact that the provider is aware, in advance, that the patient is a PFFS member and the provider has |

| |reasonable access to the Plan’s terms and conditions of payment. Members must inform providers of PFFS Plan membership and |

| |present their ID card prior to receiving covered services. If the provider does not agree to be deemed, the PFFS member |

| |must find another provider. Providers agree to bill the plan and will not balance bill the member. |

| |  |

| |A provider must agree to be deemed each time a member seeks covered medical services. The provider can decide whether or |

| |not to accept the Plan’s terms and conditions of payment each time they see a PFFS member. A decision to treat one plan |

| |member does not obligate the provider to treat other PFFS members, nor does it obligate providers to accept the same member|

| |for treatment at a subsequent visit. |

|Doughnut Hole (CMS preferred term |Name for the step in a Part D Plan in which members pay all expenses for eligible medications, until they have spent |

|is coverage gap) – (MAPD & Part D) |$4,550. See coverage gap. |

|Drug Utilization Management – UM – |Drug claims processing coverage rules utilized to advocate clinically appropriate, cost-effective medication use in an |

|(MAPD & Part D) |effort to minimize unnecessary cost to the benefit. |

|Dual Eligible |Consumers and/or members receiving benefits from both Medicare and Medicaid. |

|Educational Event |Is defined by the way in which an event is marketed to a consumer. The purpose is to provide information about the Original|

| |Medicare program and/or health improvement and wellness. These events may not include any sales activities such as the |

| |distribution of marketing materials or the distribution or collection of plan enrollment applications. |

|End-Stage Renal Disease – ESRD |Permanent kidney failure requiring dialysis or a kidney transplant. |

|Exception – (MAPD & Part D) |A type of coverage determination that, if approved, allows a Part D Plan member to obtain a medication that is not on the |

| |Plan sponsor’s formulary or to obtain a non-preferred medication at the preferred cost-sharing level (a tiering exception).|

|Excluded Medications – (MAPD & Part|Medications that are not housed within the benefit. These medications may be excluded due to a Plan sponsor’s business or |

|D) |clinical decision to not cover the medication or they could be excluded because the Medicare Modernization Act (MMA) |

| |excludes the medications. |

|Federal Poverty Level – FPL |Is used to determine financial eligibility for certain programs. Guidelines vary by family size. In addition, there is one |

| |set of FPL figures for the 48 contiguous states and D.C.; one set for Alaska; and one set for Hawaii. |

|Formulary |A list of medications covered within the benefit plan; often represents the level of cost-sharing associated with various |

| |groupings of medications (Generics, Preferred Brand, Non-Preferred Brands). The formulary is often published to the web or |

| |in a written document. However the document may only reference the preferred medications. (Often referred to as Preferred |

| |Drug List or PDL). |

|Full Dual Eligible |Consumers and/or members eligible for both Medicare and full Medicaid benefits. |

|Generic Drugs |A prescription drug that has the same active ingredients as a brand name drug. Generic drugs usually cost less than brand |

| |name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Also |

| |known as Generic Medications. |

|Grandfathering – (MAPD & Part D) |Allows for continued coverage of specific therapies that may have been covered previously, but are no longer being covered |

| |after a formulary or benefit change. |

|Group Retiree |A Group Retiree is an individual who has retired from his/her previous employer and is looking to continue health care |

| |and/or prescription coverage with their previous employer. Health plans have existing relationships with employer groups |

| |which allow them the opportunity to offer products and administer benefits for Group Retirees through contractual |

| |agreements and arrangements. With Endorsed plans, the employer does not pay any portion of the premium, but with the |

| |Subsidized plans they do. |

|Guaranteed Issue |When insurance companies are required by law to sell or offer consumers a Medigap policy.   In these situations, an |

| |insurance company can’t deny consumers a Medigap policy, or place conditions on a Medigap policy, such as exclusions for |

| |pre-existing conditions, and can’t charge consumers more for a Medigap policy because of past or present health problems. |

|Health Insurance Claim Number – |Consumer’s Medicare identification number. |

|HICN | |

|HMO |Health Maintenance Organization. |

|Initial Coverage Limit – ICL – |The maximum limit of coverage under the initial coverage period. |

|(MAPD & Part D) | |

|Initial Coverage Period – ICP – |The period after a PDP Plan member has met their deductible and before their total medication expenses have reached $2,830 |

|(MAPD & Part D) |(the 2010 ICL) including amounts the member has paid and what the Plan has paid on their behalf. |

|Late-Enrollment Penalty – LEP – |An amount added to a consumer’s monthly premium for Medicare Part A and/or Part B, or for a Medicare drug plan (Part D), if|

|(MAPD & Part D) |they do not elect to join when they are first eligible. Consumers pay this higher amount as long as they have Medicare. |

| |There are some exceptions. |

|Long-Term Care Pharmacy – LTC – |A pharmacy owned by or under contract with a long-term care facility to provide prescription medications to the facility’s |

|(MAPD & Part D) |residents. |

|Low Income Copayment – LIC – (MAPD |Reduced prescription copayment level for the member. |

|& Part D) | |

|Low Income Subsidy – LIS – (MAPD & |A program from Medicare to help consumers, with limited income and resources, pay prescription medication costs. |

|Part D) | |

|Marketing/Sales |Steering or attempting to steer a consumer toward a plan or limited number of plans. |

|Maximum Allowable Cost – MAC – |The highest dollar amounts that the Federal government will pay for medication that is dispensed to a Medicare or Medicaid |

|(MAPD & Part D) |consumer. |

|Medicaid |A program that pays for medical assistance for certain individuals and families with low incomes and resources. Medicaid is|

| |jointly funded by the Federal and State governments to assist states in providing assistance to people who meet certain |

| |eligibility criteria.   Medigap cannot be sold to individuals who receive assistance from Medicaid unless assistance is |

| |limited to help with Part B premiums, or Medicaid buys the Medigap Plan for the individual. |

|Medicare |A Federal government health insurance program for: |

| |•         People age 65 and older |

| |•         People of all ages with certain disabilities |

| |•         People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney |

| |transplant) |

|Medicare Advantage "Medical Only" |A Medicare Advantage Plan with only medical coverage. It does not have an integrated Part D prescription medication |

|Plan – MA Only – (MAPD) |benefit. |

|Medicare Advantage Plans |Health plans offered by private insurance companies that contract with the Federal government to provide Medicare coverage.|

| |Medicare Advantage Plans may be available both with and without Part D Plans. Medicare Advantage Plans may also be referred|

| |to as Medicare Health Plans. |

|Medicare Advantage Prescription |A Medicare Advantage Plan that integrates Part D prescription drug benefits with the medical coverage. |

|Drug – MAPD – (MAPD) | |

|Medicare Part A |The part of Medicare that provides help with the cost of hospital stays, skilled nursing services following a hospital |

| |stay, and some other kinds of skilled care. |

|Medicare Part B |The part of Medicare that provides help with the cost of physician visits and other medical services. |

|Medicare Part B Premium |The premium amount deducted from a Medicare consumer's Social Security check. Most people will pay the standard premium |

| |amount of $96.40 in 2009. The monthly premium will be higher if the yearly income is greater than $85,000 for individuals |

| |and $170,000 for married couples. The Part B Premium varies from year to year. |

|Medicare Part C – (MAPD) |Medicare Part C Plans are referred to as Medicare Advantage Plans. |

| |•  Include both Part A (Hospital Insurance) and Part B (Medical Insurance) |

| |•  Private insurance companies approved by Medicare provide this coverage |

| |•  In most plans, members need to use plan physicians, hospitals and other providers or they pay more |

| |•  Members usually pay a monthly premium (in addition to their Part B premium) and a copayment for covered services |

| |•  Costs, extra coverage and rules vary by plan |

|Medicare Part D – (MAPD & Part D) |Known as Medicare Prescription Drug Plans. The part of Medicare that provides coverage for outpatient prescription |

| |medications. These plans are offered by insurance companies and other private companies approved by Medicare. Consumers can|

| |get Part D coverage as part of a Medicare Advantage Plan (if offered where a consumer lives), or as a Stand-alone |

| |Prescription Drug Plan. |

|Medicare Private Fee-for-Service |Medicare Advantage Plans offered by private insurance companies that allow members to go to any Medicare eligible provider |

|Plan – PFFS |who agrees to accept the PFFS Plan's terms and conditions of payment rates. The PFFS Plan pays instead of Original |

| |Medicare. PFFS Plans may or may not offer Part D coverage. |

|Medicare Savings Plan – MSA – |A type of Medicare Advantage Plan. MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan|

|(MAPD) |deposits money from Medicare in the account. Consumers can use it to pay their medical expenses until their deductible is |

| |met. |

|Medicare Savings Programs – MSP |Many older adults have low incomes, but not low enough to qualify for Medicaid. There are several Medicare Savings Programs|

| |available under Medicaid to help lower income seniors and disabled individuals pay for some of their out-of-pocket medical |

| |expenses. They are: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified |

| |Individual 1 (QI-1), Qualified Disabled and Working Individual (QDWI). |

|Medication Therapy Management – |A type of Drug Use Review and associated interventions which look to address members’ safety and cost concerns through |

|(MAPD & Part D) |prescriber consultation and member pharmacist counseling. The service is required by the Medicare Modernization Act and |

| |targets members with complex medication regimens and costly medication expenditures. |

|Medigap Policy |Medicare Supplement insurance sold by private insurance companies to fill "gaps" (deductibles, coinsurance, copayments) in |

| |Original Medicare. A Medigap Policy can not be sold to a Medicare Advantage member unless the member is switching to |

| |Original Medicare. A Medigap Policy can and is sold to members in Part D (not MAPD) Plans. |

|Member |  A term when used refers to the customer, beneficiary, lead, consumer or prospect for all products. |

|MIPPA |Medicare Improvements for Patients and Providers Act of 2008. |

|Monthly Plan Premium |The fee a member pays if they belongs to a Medicare Advantage Plan (like HMO or PPO), in addition to the Medicare Part B |

| |premium for covered services, if applicable. |

|Monthly Premium (Part D) |Most drug plans charge a monthly fee that varies by plan. Members pay this in addition to the Medicare Part B premium. If a|

| |member belongs to a Medicare Advantage Plan (like HMO or PPO) or a Medicare Cost Plan that includes Medicare prescription |

| |drug coverage, the monthly premium may include an amount for prescription drug coverage. |

|Multi-Source Brand |A brand name medication that has a generic equivalent. |

|National Drug Code – NDC – (MAPD & |An eleven-digit number assigned to all prescription medication products by the manufacturer or distributor of the product |

|Part D) |under FDA regulations. An NDC number is composed of three distinct parts: the first five digits identify the drug |

| |manufacturer, the next four identify the drug composition, strength and dosage form, and the last two identify the package |

| |size. |

|Network – (MAPD & Part D) |Group of physcians, hospitals and pharmacies who have contracts with a health insurance plan to provide care/services to |

| |the plan’s members. The Part D prescription drug plan’s network of pharmacies may help members save money on medications. |

|Network Pharmacy |A licensed pharmacy that is under contract with a Part D sponsor to provide covered Part D drugs at negotiated prices to |

| |its Part D Plan members. |

|Nominal Value |Items or services worth $15 or less based on the retail purchase price. |

|Open Enrollment Period – (Medicare |A one-time only, six-month period when federal law allows consumers to buy any Medigap Policy they want that is sold in |

|Supplement Plans) |their state. It starts in the first month that a consumer is covered under Medicare Part B and is age 65 or older.   Some |

| |states may have additional open enrollment rights under state law. During this period, consumers can not be denied a |

| |Medigap Policy or charged more due to past or present health problems. |

|Open Enrollment Period – OEP – |January 1st to March 31st annually. The enrollment period when a Medicare consumer may make changes to their previously |

|(MAPD) |chosen Medicare coverage. A consumer may not add or drop prescription medication coverage during the OEP. Elections made |

| |during this period will become effective on the 1st of the following month. |

|Original Medicare |One of the consumer’s health coverage choices as part of Medicare. |

| |•  Part A (Hospital Insurance) and Part B (Medical Insurance) |

| |•  Medicare provides this coverage. |

| |•  Consumers have a choice of physicians, hospitals and other providers. |

| |•  Generally, consumers pay deductibles and coinsurance |

| |Consumers usually pay a monthly premium for Part B |

| |  |

|Out-of-Network Pharmacy – OON – |A licensed pharmacy that is not under contract with a Part D sponsor to provide negotiated prices to Part D Plan members. |

|(MAPD & Part D) | |

|Out-of-Network Provider |A licensed physician or hospital that is not contracted with UnitedHealthcare to provide medical services to its members.  |

| |With Medicare Advantage PPO and POS plans, members can access out-of-network providers for covered services, generally at a|

| |higher cost than with in-network providers. |

|Out-of-Pocket Maximum – OOP Max - |An annual limit that some plans set on the amount of money a member will have to spend out of their own pocket for |

|(MAPD & Part ) |benefits. |

|Pharmaceutical & Therapeutic |The committee of physicians, pharmacists, and other health care professionals who establish and approve the clinical |

|Committee – P&T – (MAPD & Part D) |parameters for a formulary. The P&T includes specialized practitioners such as geriatricians and pharmacists specializing |

| |in geriatrics. The committee includes independent consultants and functions under policies that ensure fair/unbiased |

| |assessments of therapies and remove conflicts of interest. |

|Pharmacy Benefit Manager – PBM |The subcontractor of the plan sponsor responsible for processing the pharmacy claims and/or administering coverage |

| |determinations. May also be referred to as the Prescription Benefit Administrator (PBA). |

|Plan Benefit Package – PBP – (MAPD |Each plan or PBP has specific benefits and cost-sharing associated with it. Each PBP is tied to a single Bid Pricing Tool |

|& Part D) |(BPT), both of which are submitted to CMS in June of each year for a 1/1 effective date for the following year. |

|Point-of-Service – POS – (MAPD) |An HMO option that lets members use physicians and hospitals outside the plan's contracted provider network subjected to |

| |increased cost sharing, POS benefits are available for selected benefits.   |

|Preferred Provider Organization – |A type of Medicare Advantage Plan in which the member can use either preferred physicians or hospitals, or go to |

|PPO – (MAPD) |non-preferred physicians and hospitals. If the member uses non-preferred providers, they will usually pay a larger share of|

| |the cost of their care. |

|Premium |The periodic payment to Medicare, an insurance company, or a health plan for health or prescription drug coverage. |

|Prescription Drug Plan – PDP – |A stand-alone plan that offers Part D prescription medication coverage only. |

|(MAPD & Part D) | |

|Primary Care Physician – PCP – |A physician seen first for most health problems. The PCP may also coordinate a member’s care with other physicians and |

|(MAPD) |health care providers. In some Medicare Advantage Plans, members must see their PCP before seeing any other health care |

| |provider. |

|Prior Authorization – PA |A type of utilization management program that requires that before the plan will cover certain services/prescriptions, a |

| |consumer and/or their physician must contact the plan. A member’s physician may need to show that the service/medication is|

| |medically necessary for it to be covered. |

|Qualified Individuals – QI-1 |A Qualified Individual Program is a limited expansion of SLMB and granted on a first-come first-serve basis. In the |

| |Qualified Individual Program, Medicaid assists with payment of the Medicare Part B premium only. |

|Qualified Medicare Beneficiary – |Qualified Medicare Beneficiary Program in which Medicaid provides payment of: |

|QMB – (MAPD) |•         Medicare Part A monthly premiums (when applicable) |

| |•         Medicare Part B monthly premiums and annual deductible |

| |•         Payment of coinsurance and deductible amounts for services covered under both Medicare Parts A and B |

|Quantity Limits – QL – (MAPD & Part|A management tool that is designed to limit the use of selected medications for quality, safety, or utilization reasons. |

|D) |Limits may be on the amount of the medication that the plan covers per prescription or for a defined period of time. |

|Referral – (MAPD) |A formal recommendation by the member's contracting primary care physician (PCP) or his/her contracting medical group to |

| |receive health care from a specialist, contracting medical provider, or non-contracting medical provider. |

|Region – (MAPD & Part D) |Prescription drug plans (PDP Plans) and Regional PPO (MAPD Plans) are offered by regions. The Centers for Medicare & |

| |Medicaid Services created regions based on population size so that plans within a region are able to enroll and provide |

| |appropriate services to consumers. At times a state is a region and at other times a region will include several states or |

| |several counties within a state. The PDP regions and Regional PPO regions are not always the same service area. |

|Regional Preferred Provider |A type of Medicare Advantage Plan. The MMA introduced the Regional PPO option in an effort to expand the reach of Medicare |

|Organization – RPPO – (MAPD) |managed care to Medicare consumers, including those in rural areas. The RPPOs can only be offered in an MA Region which is |

| |defined by CMS. |

|Service Area – (MAPD) |Is the geographic area approved by CMS within which an eligible consumer may enroll in a certain plan. |

|SNF |Skilled Nursing Facility |

|Special Election Period – SEP |A period when a Medicare consumer may sign up or make changes to their Medicare coverage outside of a general enrollment |

| |period. These periods are available under specified circumstances defined by Medicare. Also referred to as Special |

| |Enrollment Period. |

|Specified Low Income Medicare |A Specified Low-Income Medicare Beneficiary Program in which Medicaid provides payment of the Medicare Part B monthly |

|Beneficiary – SLMB |premium only. |

|State Pharmaceutical Assistance |A State program that provides help paying for medication coverage based on financial need, age or medical condition. |

|Programs – SPAP – (MAPD & Part D) | |

|Step Therapy – ST – (MAPD & Part D)|A utilization tool that requires a member to first try another medication to treat their medical condition before the Part |

| |D Plan will cover the medication their physician may have initially prescribed. |

|Therapeutic Alternatives |Drug products containing different chemical entities, but which provide the same pharmacological action or chemical effect |

| |when administered to patients in therapeutically equivalent doses. |

|Therapeutic Class |Drugs grouped by their purpose, the symptom or disease they are used to treat. |

|Therapeutic Substitution |A decision by a physician to replace a prescribed medication with a similar medication that is more effective or equally |

| |effective. |

|Tier – (MAPD & Part D) |Covered medications have various levels of associated member cost-sharing. Example: Tier One (primarily Generics); Tier Two|

| |(primarily Preferred Branded Medications); Tier Three (primarily Non-Preferred Branded Medications); Tier Four (Specialized|

| |High Cost Medications). |

|Tier Exceptions – (MAPD & Part D) |A type of coverage determination to provide coverage (based on clinical justification) of a Tier Three (Non-Preferred Brand|

| |Drug) prescription at the Tier Two (Preferred Brand Drug) coverage level. Tier Exceptions are not applicable to Tier Four |

| |products (Specialty Tier) or Tier Two products (Preferred Brands). |

|True Out-of-Pocket Expense – TrOOP |An accumulation of payments – monies spent – by the member of a plan. This will included copayments and deductibles, but |

|– (MAPD & Part D) |does not include premium payments or any payments made by the plan. |

|Yearly Deductible |The amount a member must pay for health care before the plan begins to pay. |

|Yearly Deductible (Part D) |The amount the member pays for prescriptions before the plan begins to pay. Some drug plans charge no deductible. |

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