A legal document that controls decisions about your health care. You also have the right to give instructions for health care providers to follow if you become unable to direct your own care, an Advance Directive can be used in these circumstances.
The amount you must pay for your health care or prescriptions before Original Medicare, your prescription drug plan, your Medicare Health Plan, or your other insurance begins to pay. These amounts can change every year. If "Under Review" appears, it means that the coverage is still being discussed by Medicare and the plan.
A set time each fall when members can change their health or drug plans or switch to Original Medicare. The Annual Enrollment Period is from October 15 until December 7.
Any individual or entity, other than Elixir Insurance, that is liable or legally responsible to pay expenses, compensation or damages in connection with a beneficiary’s injuries or illnesses. Another Party shall include the party or parties who caused the injuries or illness (first or third parties); the insurer, guarantor or other indemnifier of the party or parties who caused the injuries or illness; a beneficiary’s own insurer, such as uninsured, underinsured, pharmacy payments, no-fault, homeowner’s, renter’s, or any other liability insurer; a workers’ compensation insurer; a pharmacy malpractice or similar fund; and any other person, corporation, or entity that is liable or legally responsible for payment in connection with the injuries or illness.
An appeal is something you do if you disagree with a decision to deny a request for coverage of prescription drugs or payment for drugs you have already received. You may request an appeal if we don't pay for a drug you think you should be able to receive.
The average amount you might expect to spend each year for prescription drugs, depending on your health status.
A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand-name drugs are protected by a patent for approximately 20 years. Until that expires, only the original company can make the drug.
Once your spending on prescription drugs reaches a certain amount called the out-of-pocket threshold, you automatically get "catastrophic coverage." Catastrophic coverage means that you only pay a small coinsurance amount or a copayment for covered drugs for the rest of the year.
This is the federal agency that administers several health care-related programs including Medicare and Medicaid.
An amount you may be required to pay as your share of the cost for health care services or prescriptions after you pay any deductibles. Coinsurance is usually a percentage of the costs, for example 20 percent.
The formal way to make a complaint is called "filing a grievance." You can file a grievance only for certain types of problems, including quality of care, wait times, and the customer service you receive.
Compounded medications are prescription drugs that are customized to an individual patient's needs. Examples include blending medication ingredients into a topical cream
An amount you may be required to pay as your share of the cost for health care services, like a doctor's visit, or prescriptions. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.
The amount you may be required to pay as your share of the cost for health care services or prescriptions. Cost-sharing can include copayments, coinsurance and/or deductibles.
Every drug on the list of covered drugs is in one of five cost-sharing tiers. In general, the higher the number (1-5) of the cost-sharing tier, the higher your cost for the drug.
A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you must pay for the prescription. Coverage determination is not the same as coverage. If you are told at the pharmacy that your drug isn't covered, you must contact your plan and ask for a formal decision about coverage.
Medicare drug plans may have a ""coverage gap,"" which is sometimes called the ""donut hole."" This means that after you and your drug plan have spent a certain amount of money for covered drugs, you may have to pay more for your drugs (until you reach the out-of-pocket threshold). Note: If you get extra help paying your drug costs, you won't have a coverage gap. However, you will probably still have to pay a small copayment or coinsurance amount.
The term used to mean all of the prescription drugs covered by your plan.
Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.
The amount you must pay for health care services or prescriptions each year, before your Medicare drug plan, your Medicare Health Plan or your other insurance begins to pay. These amounts can change every year.
The term for ending your health care and/or prescription drug coverage with a health plan or drug plan.
The prescribed strength or amount of therapeutic ingredient(s) administered at prescribed intervals.
This refers to whether a specific prescription drug is covered by your drug plan.
The plan may have certain coverage restrictions (including quantity limits, prior authorization, and step therapy) on a prescription drug.
Some people who are eligible for both Medicare and Medicaid are called "dual eligibles."
Drugs on a formulary are often organized into different drug ""tiers."" 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. Look at the specific plan details offered by Elixir Insurance to see specific Tiers for available plans, or if you are a member, you can login to the Member Portal or review your Evidence of Coverage.
Plans that give health and/or drug 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.
This is a tool that helps you estimate the amount of money you might expect to spend each year for your health coverage. The estimates include the following: Plan benefits (coverage) Costs for premiums, copayments, deductibles, coinsurance Costs not covered by your insurance Your out-of-pocket costs are based on actual health coverage use by people with Medicare, and they may differ depending on your age and health status. If you have limited income and resources, your expenses may be lower.
This is an estimate of the average amount you might expect to pay each year for your prescription drug coverage. This estimate includes the following costs, as applicable: Monthly premiums Annual deductible Drug copayments/coinsurance Drug costs not covered by prescription drug insurance If you entered your drugs into the Medicare Plan Finder, then this estimate includes the cost of those drugs. If you selected ""I don’t take any drugs,"" then this amount includes only the cost of the monthly premiums that you would pay for the plan and it does not include any drug costs. If you selected ""I don’t want to add drugs now,"" then this estimate includes the average drug costs for people with Medicare and may differ depending on your age and health status. Your expenses may be lower if you have limited income and resources.
This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what the plan must do, your rights, and what you have to do as a plan member.
A type of coverage determination that, if approved, allows you to do one of several things: 1) get a drug that is not on your plan's formulary, 2) get a non-preferred drug at a lower cost-sharing level, 3) not be required to try another drug before receiving the drug you're requesting or 4) get a higher quantity of medication than your plan typically allows. Exceptions are made after a formal request is made.
A Medicare program that helps people with limited income and resources pay for Medicare prescription drug program costs such as premiums, deductibles, and coinsurance. People who get partial Extra Help may pay a low annual deductible and a small percentage of their monthly Medicare drug plan premium, depending on their income and resources. Please visit Extra Help page for more information.
How often you refill your prescription.
The total costs for your selected drugs when you use a network retail pharmacy. Actual amounts may vary depending on the number of months left in the year.
The total costs for your selected drugs if your enrollment starts at the beginning of next month. Costs calculations account for months that have already passed.
The total costs for your selected drugs if your enrollment starts in January.