Annual Medical Deductible:
The amount you pay first, before your plan starts to pay. This is usually an annual fee. Many Medicare Advantage plans have low or $0 deductibles.
Annual Prescription Drug Plan Deductible:
A deductible is a dollar amount you (or others on your behalf) must pay before your benefit plan will begin to contribute to the cost of your medications.
An appeal is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if a plan doesn't pay for a drug, item, or service you think you should be able to receive.
Items and services covered by your insurance plan. Medicare Advantage plans must provide all the same benefits covered by Medicare Part A and Part B. Many Medicare Advantage plans also offer additional plan benefits.
The drug payment stage in the Medicare Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent in covered drugs costs.
A claim is a request for payment for the medical services you've received. If your services are covered, your insurance company pays your claim, less any required copay, deductible or other costs that aren't covered. If services aren't covered, you may be responsible for paying the claim.
A kind of cost sharing where you pay a percentage of the cost of a service. For example, a plan might pay 75% and you would pay 25%. In Medicare Advantage, coinsurance varies depending on the plan.
Copayment or copay:
A preset amount you pay for a service, such as an annual check-up or prescription drug.
A name for the drug payment stage in a Medicare prescription drug plan in which you (or others on your behalf) usually pay all of your expenses for eligible drugs. In , the coverage gap begins after you and the plan together have spent in total yearly drug costs. During the coverage gap, you (or others on your behalf) will pay 50% of your brand name prescription drug costs (plus the dispensing fee) and the majority of the costs for your generic prescription drugs until the total amount you (or others on your behalf) have paid reaches in year-to-date out-of-pocket costs. Out-of-pocket costs are the amount you pay or others pay on your behalf toward the cost of your prescription drugs including deductible, copays, coinsurance and payments made in the coverage gap. Premiums do not count toward out-of-pocket costs.
Also called a drug list. This is a list of prescription drugs covered by a Medicare Part D plan. In most cases, Medicare Advantage plans include Part D coverage. Formularies vary depending on the plan.
A type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Health Maintenance Organization. A type of coordinated care health plan in which you receive care through a network of local doctors and hospitals. You must select a primary care physician to oversee your care. This type of plan generally offers lower costs, but a more limited choice of health care providers.
A name for the drug payment stage in a Medicare prescription drug plan in which you have met your annual deductible (if applicable), and you (or others on your behalf) pay copays or coinsurance for each prescription filled. The plan pays the remainder until together you have paid .
Medicare Advantage (MA) plans:
Sometimes called Medicare Part C. These plans provide your Medicare Part A (Hospital) and Part B (Medical) benefits, plus additional benefits. In most cases, Medicare Advantage plans also offer Medicare Part D prescription drug coverage. A Medicare Advantage plan can be an HMO, a PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan.
Medicare Medical Savings Account (MSA) plan:
A type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account. Members use their savings account to help pay for health care, and then have coverage through a high-deductible insurance plan once they reach their deductible.
The amounts you pay as your share of your costs in a plan after you have paid any premium. Out-of-pocket costs include deductibles, copayments and coinsurance.
Preferred Provider Organization. A type of coordinated care health plan in which you have a network of health care providers within your plan's network. This type of plan also gives you the flexibility to receive covered services from any accepting doctor or hospital outside your network. Typically, receiving services outside the network generally results in a higher copayment or coinsurance.
The amount you pay to have an insurance plan. This is usually a monthly fee. Many Medicare Advantage plans do not have monthly premiums.
Private Fee-for-Service (PFFS) plan:
In this type of Medicare Advantage health plan, you choose from doctors or hospitals that accept the terms, conditions and payment rates of your plan. These plans are generally the most flexible, but tend to have higher costs than with other Medicare Advantage plans. Doctors or hospitals who accept the plan conditions are called 'deemed'. Providers have the right to decide if they will accept the plan each time they see you.
This is the group of doctors, hospitals, pharmacies and other health care facilities that have contracted with an insurance plan to provide care to plan members.
Total drug costs:
The amount you (or others on your behalf) pay plus the amount the plan pays starting January 1. Premiums are not included in total drug costs.