Glossary

Annual Coordinated Election Period
The time each year when you can enroll or change plans. For Medicare Prescription Drug Plans, this is November 15 through December 31.

Appeal
A request to reconsider and change a decision made about a health care service, drug authorization, or prescription or medical claim.

Base Beneficiary Premium
An amount, set by CMS, based on bids submitted by Part D carriers. Final member premiums are calculated using a carrier’s specific bid and the base beneficiary premium.

The 2010 base beneficiary premium published by CMS is $31.94. Using that number in combination with Medi-CareFirst’s bid, CMS determined that the 2010 monthly rate for Blue Rx Standard (PDP) is $74.40. Part D late enrollment penalties are based on the base beneficiary premium ($31.94), not on the member premiums ($74.40).

Brand-Name drug
A prescription drug that has been patented and is only available through one manufacturer.

Care Management
Case management and disease management for those with chronic health care conditions. Services can include a 24-hour health coach to offer support to members facing lifestyle issues or chronic conditions; educational materials; licensed nurses who help to coordinate necessary health care services with the various doctors and hospitals and provide support to the family with disease-specific information, and provide links to community resources; nurses who help those with chronic diseases follow recommended tests and exams and understand the required medical recommendations to help improve the person's ability to care for themselves.

Catastrophic Coverage
After you have paid $4,550 in out-of-pocket costs, you will only pay the greater of 5% or $2.50 for Generics/Brands treated as Generic drugs and $6.30 for other drugs.

Centers for Medicare and Medicaid Services (CMS)
The Federal agency that runs the Medicare program.

Coinsurance
The amount the member pays for certain covered drugs or services. Coinsurance is a percentage of the actual cost.

Coordination of Benefits
The process for making sure that all of your insurance plans which cover your drug or medical costs have paid their share of the cost.

Copayment (Copay)
A set dollar amount the member pays for certain covered drugs or medical services, like a doctor’s visit.

Cost Sharing
A term indicating that a member must pay some part of the cost. Deductibles, copays and coinsurance are types of cost sharing.

Cost-sharing Tier
Every drug on the formulary (list of covered drugs) is in one of 4 cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.

Coverage Determination
A coverage determination is a decision from your Medicare drug plan about whether a drug you need is covered by the plan and how much you must pay for the prescription.  This includes decisions concerning tier exceptions, and prior authorization or other utilization management requirements.

Coverage Gap
Sometimes called the “doughnut hole,” a coverage gap means that after you and your plan have spent a certain amount of money for covered drugs, you have to pay all out-of-pocket costs for your drugs while you are in the “gap.”

Covered Drugs
All prescription drugs that are covered by Medi-CareFirst prescription drug plans.

Creditable Prescription Drug Coverage
Coverage that is as good as or better than the standard Medicare Prescription Drug coverage.

Deductible
This is the amount you must pay before the insurance company (Medi-CareFirst) or Medicare begins to pay its portion of the claims.

Disenroll or Disenrollment
The process of ending your membership with Medi-CareFirst plans. Disenrollment can be voluntary (your choice) or involuntary (not your choice).

Durable Medical Equipment (DME)
Goods, implements, prosthetics, etc., that are prescribed for patient care, usually in an outpatient setting. Examples include hospital beds, wheelchairs and walkers.

Evidence of Coverage
A document which, along with your enrollment form and other attachments, explains your covered services, defines Medi-CareFirst's obligations and explains your rights and responsibilities as a member.

Exception
A request to Medi-CareFirst to pay for a drug that is not covered, to pay for a drug at a different cost, or to waive restrictions or limits on your drug.

Formulary
For Medicare Prescription Drug Plans, the formulary is all of the drugs the insurance plan covers. Medi-CareFirst's formulary covers all of the drugs Medicare will pay for under its Part D prescription drug coverage, except some prescription drugs of certain strengths that are also available over-the-counter. Also called the list of covered drugs.

Generic Drug
Prescription drugs that have the same active ingredient formula as Brand-Name drugs. Generic drugs usually cost less than Brand-Name drugs and are required by the Food and Drug Administration (FDA) to be as safe and as effective as the Brand-Name drug.

Grievance
A complaint about the way you receive your Medicare Prescription Drug or Health Plan's coverage. For example, if you do not like the way you are treated by the Medi-CareFirst staff when you call, you would file a grievance. (Note: if you are unhappy with a coverage decision, you would file an appeal.)

Group Health Plan
A health plan that provides coverage to employees (or retirees), former employees, and their families, and is supported by an employer or employee organization (such as a union).

Home Care
Skilled nursing and related services provided to patients in a home setting. Other home care services include physical therapy, occupational therapy, speech therapy, medical social services, home health services, and medical supplies and equipment.

Hospice
A program or facility that provides care, comfort and support services for terminally ill patients and their families. Hospice care concentrates on reducing the severity of disease symptoms, rather than halting or delaying progression of the disease itself.

Initial Coverage Limit
The maximum limit of coverage under the Initial Coverage Stage.

The Initial Coverage Limit is $2830.

Initial Coverage Stage:
For Blue Rx Standard (PDP), this is the stage after you have met your $150 deductible and before your total drug expenses have reached $2830 including amounts you've paid and what Medi-CareFirst has paid on your behalf during the calendar year. For Blue Rx Enhanced (PDP), this is the stage before your total drug expenses have reached $2830, including amounts you've paid and what Medi-CareFirst has paid on your behalf during the calendar year.

Late Enrollment Penalty
The additional cost you will have to pay if you do not have creditable prescription drug coverage and enroll in a Medicare Prescription Drug Plan outside your regular open enrollment period. The penalty is in addition to your monthly premium. The penalty lasts as long as you are enrolled in a Medicare Prescription Drug program.

List of Covered Drugs (Formulary or "Drug List"):
A list of covered drugs provided by Medi-CareFirst. Medi-CareFirst's formulary covers all of the drugs Medicare will pay for under its Part D prescription drug coverage, except some prescription drugs of certain strengths that are also available over-the-counter.

Low Income Subsidy/Extra Help:
A Medicare program to help people with limited incomes and resources pay Medicare prescription drug plan costs, such as premiums, deductibles, and coinsurance.

Medically Necessary:
Drugs that are used for the diagnosis, care, and treatment of your medical condition and meet the standards of good medical practice in the local community.

Medicare
The federal health insurance program for people 65 years of age or older; some people with disabilities who are under age 65; and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). Also called "Original Medicare," "Traditional Medicare," or "Fee-for-Service" Medicare.

Medicare Advantage Plans
A plan offered by a private insurance company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits.  If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. Sometimes called Medicare Part C.

Medicare Advantage Private Fee-for-Service (PFFS) Plan
A type of Medicare Advantage plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment terms and conditions. 

Medicare Prescription Drug Coverage (Medicare Part D):
Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.

Medigap (Medicare Supplemental Insurance)
Insurance coverage purchased to cover costs Medicare does not cover.

Member
A person who has enrolled in a Medi-CareFirst plan and whose enrollment has been confirmed by the Centers for Medicare and Medicaid Services (CMS).

Multisource Drug
A Preferred Brand-Name drug that the drug manufacturer offers to your insurance plan at the same cost as the Generic drug.

Network Pharmacy (In-Network pharmacy)
Pharmacies which have contracted with Medi-CareFirst to provide prescription drug benefits. In most cases, your prescriptions are only covered if they are filled at a network pharmacy.

Non-Network Pharmacy (Out-of-Network pharmacy)
A pharmacy which has not contracted with Medi-CareFirst to provide prescription drug benefits.

Non-Preferred Brand-Name Drugs
Brand-Name drugs that are available to members at a higher cost when similar lower cost Brand-Name drugs or Generics are available.

Non-Self Injectable Drug
Any injectable drug that is administered by someone else, and that is not covered under Medicare Part A or B.

Organization Determination
Our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received.

Outpatient
An outpatient is a patient who is not hospitalized overnight but who visits a hospital, clinic, or associated facility for diagnosis or treatment and is treated and discharged on the same day.

Out-of-Pocket Costs
Health care costs that you must pay on your own because they are not covered by Medicare or other insurance.

Part C:
See"Medicare Advantage Plans"

Part D:
See "Medicare Prescription Drug Coverage"

Part D Drugs:
Drugs that can be covered under Part D. Medi-CareFirst covers all of the drugs Medicare will pay for under its Part D prescription drug coverage, except some prescription drugs of certain strengths that are also available over-the-counter.

Preferred Brand-Name Drugs
Brand-Name drugs that the Medi-CareFirst plan has found to be the most effective at the lowest cost.

Pre-certification Management
The practice of managing health care cases efficiently and cost effectively before and during a case. The evaluation judges the appropriateness, medical need and efficiency of health care services, procedures and facilities within the provisions of an applicable health benefits plan.

Prior Authorization
Approval in advance for certain prescription drugs or medical services. If Prior Authorization is required and not received, Medi-CareFirst may not pay for your drug or service.

Quality Improvement Organization (QIO):
Groups of practicing doctors and other health care experts paid by the Federal Government to check and improve the care given to Medicare patients. They review your complaints about the quality of care given by Medicare Providers.

Quantity Limits
A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

Representative
A person who represents your interests when you are unable to represent yourself.

Service Area
The geographic area approved by the Centers for Medicare and Medicaid Services for specific plans to offer Medicare Prescription Drug or Health coverage.  

Skilled Nursing Facility Care (SNF)
A level of care that requires the daily involvement of skilled nursing or rehabilitation staff like physical therapy and intravenous injections. You qualify only after a 3-day minimum hospital stay for a related illness or injury for up to 100 days in a benefit period that includes a semi-private room and meals. Medicare doesn't cover long-term care or custodial care in this setting.

Supplemental Security Income (SSI):
A monthly benefit paid by the Social Security Administration to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.

Tier (Cost-Sharing Tier)
The copay level assigned to a prescription drug.

• Generic drugs (Tier 1 -- $)
• Preferred Brand-Name drugs (Tier 2 -- $$)
• Non-Preferred Brand-Name drugs (Tier 3 -- $$$)
• Non-Self Injectables (Tier 4 - 25% co-insurance)