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Medicare Part D Glossary



PCP
A primary care physician you choose from a plan network to provide your routine and preventive care. HMOs require you to select a PCP, while PPOs don't. However, if you select a PCP with your PPO plan, you'll have a lower copay for office visits.

PDP
Stand-alone Medicare Part D Prescription Drug Plans (PDPs) provide reduced-cost prescription drug coverage to Medicare recipients. Medicare Part D plans work together with Medicare Part A and Part B, as well as Medicare Supplements and Medicare Advantage (MA) plans that do not provide prescription drug coverage. Annual Enrollment periods for PDPs run from Nov 15 through Dec. 31, with January 1 as the plan starting date.

PPO
A Preferred Provider Organization that provides access to a network of doctors and hospitals that coordinate your care. This allows you to get more benefits than the Original Medicare Plan and many Medicare supplement plans. PPOs also allow you to use any doctor or hospital outside of the network for a higher copay or coinsurance.

Part D (Medicare Part D)
Part D is the new prescription drug program that became available to all Medicare beneficiaries on January 1, 2006. The Medicare Part D prescription drug program is insurance offered by the federal government and sold through private companies that helps pay for prescription drugs.

penalties
Medicare beneficiaries without creditable coverage who were eligible to enroll but waited until after May 15, 2006, may pay the standard monthly premium plus a 1-percent penalty of the base beneficiary premium per month - or 12 percent a year - and won't be able to enroll until the next annual election period (November 15, 2006, through December 31, 2006). This higher premium will stay with them for as long as they are enrolled in the program. People who turn 65 between annual enrollment periods can join a Medicare prescription drug plan as soon as they sign up for Medicare. They can enroll at any time three months before or three months after their Medicare eligibility date without penalty. The effective date of prescription drug coverage will begin on their Medicare eligibility date. If they don't join a plan within three months after their Medicare eligibility date, don't have creditable coverage and decide to join later, they'll pay the same 1-percent penalty.

pharmacy network
This is the group of pharmacies who have contracted with the PDP to save you money on prescriptions.

policyholder
The person or party who owns an individual insurance policy. This the person may be the insured, a relative, the beneficiary, a corporation, or another person.

portability
HIPAA requires that workers with pre-existing medical conditions must receive credit for time in a previous health plan if they join an employer plan.

pre-certification
A requirement to notify the insurance company for its approval before you check into a hospital, have elective surgery, visit specialists, have testing done. Pre-certification does not guarantee the insurance company will pay the medical bills. Also called pre-admission.

pre-existing condition
Particular health conditions that occurred prior to applying for insurance and for which you received medical advice, diagnosis, care or treatment. Policies can exclude coverage of any medical condition for a period of time.

preferred brand drugs
Among brand drugs, these are the ones the plan prefers, so they are less costly. These brand drugs generally have lower co-pays than non-preferred brand drugs.

premium
The payment required annually, semi-annually or monthly to be part of an insurance plan. In a Part D plan, this is usually a monthly fee.

primary care provider
A health care professional (usually a physician) who is responsible for monitoring an individual's overall health care needs. Typically, a PCP refers the individual to more specialized physicians for specialist care.

prior authorization or prior approval
Some benefit plans require you to receive authorization or approval before they will cover a particular prescription. The reasons vary and can include the medication itself, the quantity prescribed or the frequency of its administration. Prior authorization means that you or your doctor will need to get approval from the plan before you fill your prescriptions. If you don't get approval, your drug may not be covered by the plan. Please note that prior authorizations can take up to 72 hours to process. Drugs with this condition are designated 'PA' in the formulary.

provider
doctors, hospitals, radiation departments, pharmacies and others that provide medical health care service.




Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.