Glossary of Terms

Advance care planning is a process used to identify a person's preferences regarding care and treatment at a future time, including a situation in which a person lacks the capacity to do so; for example, when a situation arises in which life-sustaining treatments are a potential option for care and the individual is unable to make his or her choices known.

Advance directives are written instruments recognized under State law identifying how you want your healthcare provided if you are unable to make your own decisions. The Arizona State Attorney General website offers Life Care Planning documents that you can download to assist you with completing your advance directives. Once completed and filed with the appropriate parties, you should provide a copy to your doctors, your hospital, and your designated Medical Power of Attorney.

Sometimes called the annual election period. AEP runs from October 15 through December 7 each year, and you can make changes to your Medicare medical plan during this time.

The Annual Notice of Change is a document that we will send to you each year in September. It outlines what will be changing about the plan for the upcoming year.

An appeal is something you do if you disagree with our decision to deny a request for coverage of prescription drugs or payment for drugs you already received. For example, you may ask for an appeal if we don't pay for a drug you think you should be able to receive. Learn more about appeals and the process for making an appeal. You can refer to Chapter 7 in your Evidence of Coverage for additional information.

The way that both our plan and Original Medicare measure your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or SNF. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in an SNF) for 60 days in a row. If you go into a hospital or SNF after one benefit period has ended, then a new benefit period begins. There is no limit to the number of benefit periods.

The stage in the Part D Drug Benefit where you pay nothing for your drugs after you or other qualified parties on your behalf have spent the max amount defined by CMS each year in covered drugs during the covered year.

The Federal agency that administers Medicare. To learn more, visit www.medicare.gov.

An amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage. For example, if your coinsurance is 20% and Medicare approves a $100 doctor office visit, Medicare will pay $80 and you will pay $20.

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay a $10 or $20 copay for a doctor's office visit.

Cost sharing refers to amounts that a member has to pay when services or drugs are received. Cost sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed “copayment” amount that a plan requires when a specific service or drug is received; or (3) any “coinsurance” amount, a percentage of the total amount paid for a service or drug, that a plan requires when a specific service or drug is received. A “daily cost-sharing rate” may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a copayment.

A set amount of money you must pay before you receive any coverage for medical services or prescription drugs. Generally, deductibles are annual and apply to Medicare Parts A, B, and D. Deductibles may also apply to Medicare Supplement plans.

The EOC explains your Medicare Advantage or Prescription Drug coverage, what your provider must do, your rights, and what is required of you as a member of our plan. The EOC is updated annually October 1 and is made available online in the documents section of this website.

The EOB is a statement that you receive every month in which you use your Medicare Advantage benefits. This statement is sent to you by your plan, and provides you with complete information regarding the prescription drug services that you have received. Also included in your EOB are any payments and costs that you are responsible for. The EOB is not a bill, but rather a statement from your plan that is provided for your convenience.

More commonly known as the drug list, the formulary is a list of drugs that are covered by the plan.

A stage that you enter after your deductible has been met, and before your total out-of-pocket drug expenses reach the CMS defined amount. Then you enter the Catastrophic Coverage Stage.

The IEP is a 7-month period that begins three months prior to your 65th birthday, continues through the month of your 65th birthday, and extends three months after your 65th birthday.

This is called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. An MA plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, Special Needs plan or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in an MA plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, MA plans also offer Medicare Part D (prescription drug coverage). These plans are called MA plans with prescription drug coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area (unless certain exceptions apply).

Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.

The Medicare Prescription Payment Plan is a payment option in the prescription drug law that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Beginning in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary.

Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage plan is not a Medigap policy).

A network pharmacy is a pharmacy that has contracted with our Part D plan, and allows our members to receive their prescription drug benefits.

Medicare Part A typically pays for inpatient hospital expenses, care in a skilled nursing facility, some home health care and hospice care.

Medicare Part B typically covers outpatient healthcare expenses, including doctor fees, outpatient care, durable medical equipment, preventative services and supplies not covered by Medicare Part A.

The part of the Medicare program that provides prescription drug coverage. Part D is offered through private health plan companies either as a stand-alone plan or included as part of a Medicare Advantage plan with prescription drug coverage.

Preferred cost sharing means lower cost sharing for certain covered Part D drugs at certain network pharmacies.

A preferred network pharmacy is a pharmacy that contracts with a Part D plan and allows the plan’s members to receive preferred cost sharing (the lowest possible copays and coinsurance) when filling their prescriptions using their plan benefit in the Initial Coverage stage.

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

A time not during the annual election period or initial enrollment period when you are able to join, change, or drop your Medicare plan. An SEP can also be triggered by certain events. For example, a change in your residence may result in an SEP.

Standard cost sharing is cost sharing other than preferred cost sharing offered at a network pharmacy.

A standard pharmacy is a pharmacy that contracts with a Part D plan and allows the plan’s members to fill their prescriptions using their plan benefit, but do not offer the same low copayments and coinsurance as a preferred pharmacy.

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