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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