GLOSSARY

UNDERSTANDING TERMS

Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care provider payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.

A pharmacy that doesn’t have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

Health or prescription drug costs that you must pay on your own because they are not covered by Medicare or other insurance. See also "cost-sharing."

Like all Medicare health plans, plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. (Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.)

Overall star ratings for plans covering drug services are based on ratings in approximately 12 different topics ranging from customer service of their call center to their appeals department to the accuracy of drug prices on Medicare's website. They also are rated on the steps they take to improve the safety of prescription drugs. To learn more about Star Ratings, visit https://www.medicare.gov/find-a-plan/staticpages/rating/planrating-help.aspx.

A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term care (LTC) services for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan. PACE is not available in all states. Learn more about PACE at https://www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html.

The container(s) your medicine comes in.

The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.

Medicare medical insurance that helps pay for certain doctors' services, outpatient hospital care, durable medical equipment, and some medical services that aren't covered by Part A.

Sometimes called Medicare Advantage Plans or "MA Plans," are offered by private companies approved by Medicare.

The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

Pharmacies that have agreed to provide members of certain plans with services and supplies at a discounted price. In some plans, your prescriptions are only covered if you get them filled at network pharmacies.

The type of pharmacy you get your medicine from. For example, a mail order pharmacy or retail pharmacy.

These plan members qualify to get Extra Help from Medicare paying their prescription drug coverage costs. This Extra Help is also known as the “Low-Income Subsidy.” People who qualify for this program get help paying their plan's monthly premiums, as well as the yearly deductible and co-payments for their prescription drugs.

A pharmacy that’s part of a Medicare drug plan’s network. You may pay lower out-of-pockets costs for some of your prescription drugs if you get them from a preferred cost sharing pharmacy instead of a standard cost sharing pharmacy.

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

Approval in advance to get certain drugs that may or may not be on our formulary. Some drugs are covered only if your doctor or other network provider gets “prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.

Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

A Medicaid program for people with Medicare who need help paying for Medicare services. The person with Medicare must have Medicare Part A and limited income and resources. For those who qualify, the Medicaid program pays Medicare Part A and Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.

Quality is how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person-and getting the best possible results.

The amount of medication you receive each time you refill a prescription.

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.

A geographic area where a prescription drug plan accepts members if it limits membership based on where people live. The plan may disenroll you if you permanently move out of the plan’s service area.

Some pharmacies have a special distinction because they distribute limited access drugs, home infusion drugs, or are considered a long term care (LTC) pharmacy. Please contact the plan to find out more about this specific pharmacy type within their network.

A Medicaid program that pays Medicare Part B premiums for people who have Medicare Part A and limited income and resources.

A network pharmacy that offers covered drugs to plan members at higher out-of-pocket costs than what the member would pay at a preferred cost sharing pharmacy.

This is the monthly amount that most people pay for services like doctors’ visits, outpatient care, durable medical equipment, and other medical services.

A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

"This is a plan's overall score based on quality and performance on a variety of topics in four categories that range from call center customer services to the appeals process and accuracy of drug prices on Medicare's website. Plans also are rated on steps taken to improve the safety of prescription drugs. This information is gathered from Medicare's regular monitoring activities, reviews of billing and other information that plans submit to Medicare, and Medicare's member surveys. Summary Rating scores related to a drug plan’s quality and performance fall under four categories. 1) Drug plan customer service: Includes how well the plan handles member appeals. 2) Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan, and how often members had problems with the plan and how the plan’s performance has improved (if at all) over time. 3) Member experience with the plan’s drug services: Includes ratings of member satisfaction with the plan. 4) Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is considered safer and clinically recommended for their condition."

SSI is a monthly amount paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits provide cash to meet basic needs for food, clothing, and shelter. SSI benefits aren’t the same as Social Security benefits.

A set time when members can change their health or drug plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting “Extra Help” with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you.

A monthly benefit paid by Social Security 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.

Elixir Insurance right to pursue the beneficiary’s claims against Another Party for pharmacy or other charges paid by Elixir Insurance.

An appeals decision is considered to be timely when it meets Medicare's appeals timeframes. The specific timeframe depends on the type of appeal and level of review in the appeals process. Appeal timeframes range from 72 hours to 30 days (and up to 60 days for some cases involving payment of a service you’ve already received). Look at the materials your plan sends you each year, such as the Evidence of Coverage. (EOC), for more details about the appeals process.

True out-of-pocket (TrOOP) costs are amounts you pay for covered Part D drugs that count towards your drug plan’s out-of-pocket threshold. Your yearly deductible, coinsurance or copayments, and what you pay in the coverage gap all count toward this out-of-pocket limit. The limit doesn’t include the drug plan’s premium.

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