If you find the many different terms used when discussing your health plan or prescription drug plan coverage to be confusing, you might find the short, simple definitions in the list below to be helpful.
Brand Name Drug:
A prescription drug manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.
The amount you pay out-of-pocket for a doctor's visit or a prescription. A co-payment is usually a set amount. For example, your co-payment could be $10 or $20 for a doctor's visit or prescription.
Cost-sharing refers to amounts that a member has to pay when drugs or services are received. It includes any fixed “copayment” amounts or any “coinsurance” amount that must be paid as a percentage of the total amount paid for a drug or service.
The prescription drugs covered by a Medicare Advantage Part D Plan. A complete list of covered drugs for our plan can be found on our ‘Drug List’ (Formulary).
The general term we use to mean all of the health care services and supplies that are covered by a Plan.
A department responsible for answering your questions about your membership and benefits.
Dispensing Limitation (DL):
For quality and safety reasons, certain drugs have a quantity limitation. Drugs with a dispensing limitation can only be filled up to the identified limit. For example, there might be a limit on refills, or how much of a drug can be received with each prescription. Drugs with dispensing limitations are noted in the drug list (formulary).
Drug List (Formulary):
A list of covered drugs provided under a Medicare Advantage Part D Plan. The list includes both brand-name and generic drugs.
Evidence of Coverage (EOC):
This detailed document explains your coverage with our plan including copayments/cost-sharing for drugs and services, procedures to follow, and any limitations or exclusions that apply to your coverage.
A prescription drug approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.
Medicare Advantage (MA) Plan (Sometimes called Medicare Part C):
A plan that contracts with Medicare to provide coverage for hospital, doctor, and outpatient services. Tufts Medicare Preferred HMO is a Medicare Advantage plan.
Prescription Drug Coverage (Medicare Part D):
Insurance to help pay for outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Part B. Tufts Medicare Preferred HMO Rx and HMO Rx Plus plans offer prescription drug coverage in addition to medical coverage.
Primary Care Physician (PCP):
A PCP is the doctor you select to provide most of your routine and preventive care and help arrange or coordinate the rest of the covered services you get as an HMO plan member. Your PCP will provide you with a referral to see specialists within his/her referral circle.
For certain drugs and services, your doctor will need to get approval from your plan before the drug or service will be covered. Sometimes plan approval is required to be sure that your drug is covered under Medicare rules. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. Covered drugs that need prior authorization are marked in the drug list (formulary) and covered medical services that need prior authorization are marked in the Evidence of Coverage.
Your PCP's approval for you to see a certain plan specialist or to receive certain covered services from plan providers. Members in our HMO plans are required to get a referral from their PCP before seeing a specialist.
Your PCP has certain plan specialists s/he uses for referrals, called a “referral circle”. This means that in most cases, you will not have access to the entire Tufts Medicare Preferred HMO network except in the case of emergencies, certain urgent care situations, or when you need specialized care not available in your medical group’s referral circle.
This requirement encourages you to try safer or more cost-effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. The objective of step therapy is to help members save money on prescription drug costs and/or try a more appropriate drug first.
Tier (‘Drug Tier’ or ‘Cost-Sharing Tier’):
Drugs listed on our formulary are also organized into cost-sharing tiers or groups of different types of drugs. Each tier represents a different cost category. The lowest tier generally offers generic drugs and has the least expensive co-pay.