Prescription/ Medical Terms
The percentage of cost that the member pays after deductible
What is coinsurance?
Approval needed from PCP to see a specialist
What is a referral?
Also known as DVH
What is dental, vision, and hearing?
Typically a one-time, 30-day supply of a drug that you were taking: Before switching to a different plan
What is a transitional fill?
The amount of money that a member with health insurance pays for each healthcare service.
What is copayment?
A health care professional who practices general medicine.
Who can be a PCP?
An allowance that can be used to buy eligible non-prescription items, plus health and wellness items.
What is a OTC Catalog benefit?
This should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary
What is a formulary exception?
The amount a member pays for healthcare services before their insurance plan starts to pay.
What is a deductible?
A state-set time period during which a person's non-covered medical expenses must be high enough to lower their available income to a level that qualifies them for Medicaid.
What is a spend-down?
Also known as The Medicare Giveback Benefit
What is the Part B premium reduction?
Trying another cheaper rx for effective results before your insurance will pay for a non-preferred prescription drug
What is step therapy?
Also known as the "doughnut hole"
What is a coverage gap?
Plans typically have lower monthly premiums and less out of pocket vs higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral
What is the difference between HMO vs PPO?
Silver Sneakers may be covered by some plans
What are fitness benefits?
You can receive lower pricing and often are allowed to get 90 day supplies of your medications vs the pricing being higher for you on each and every prescription.
What is standard vs preferred pharmacy?
Medicare drug coverage typically places drugs into different levels called
What is a tier?
Someone with both Medicare & Medicaid
What are qualifications for DSNP plans?
This benefits provides access to medical appointments, grocery shopping, and social activities.
What is a transportation benefit?
This is sometimes referred to as precertification or prior approval
What is prior authorization?