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Medicare Part D: What does this all mean? -- a glossary
Sunday, November 12, 2006

Here's a rundown of some common terms to help Medicare Part D candidates negotiate their way through the various plans:

BRAND-NAME DRUGS
Drugs that have trade names and are produced by certain manufacturers.

CO-PAY
A fee paid by consumers for a prescribed drug when the drug is dispensed.

CREDITABLE COVERAGE
Drug coverage at least as good as Part D. PACE and PACENET recipients and many retirees have creditable coverage.

DEDUCTIBLE
An amount consumers pay for prescriptions before the plan's coverage begins.

DOUGHNUT HOLE
A gap in Part D coverage that can require consumers to pay more than $3,000 of their drug costs next year after annual costs reach $2,400. Once their out-of-pocket costs reach $3,850, consumers typically pay only small co-pays for the rest of the year.

DUAL ELIGIBLE
Someone eligible for both Medicare and Medicaid.

EXCEPTIONS PROCESS
Procedures that allow exceptions to a plan's formulary restrictions or permit lower co-pays for certain drugs.

FORMULARY
A list of drugs a plan will cover. In some cases, plans will cover drugs not included on the formulary.

GENERICS
Drugs sold under their chemical names. They meet government standards for purity and effectiveness but are less expensive than brand-name drugs.

MEDICAID
A state/federal program for low-income people and certain elderly and those with disabilities who meet the financial criteria.

MEDICARE
A federal health-care program for people 65 and older or those with certain disabilities.

MEDICARE ADVANTAGE PLAN
A plan that provides doctor and hospital coverage, usually by utilizing specific networks of doctors and hospitals. Many Medicare Advantage plans are offering Part D coverage.

OUT-OF-POCKET
The share of costs a consumer pays -- for example, through co-pays or deductibles.

PACE AND PACENET
Drug assistance programs for Pennsylvania residents 65 and older.

PART D
Medicare's prescription drug program.

PREFERRED DRUG
Drugs that plans prefer their members use. They usually are available for lower co-pays. Many plans provide coverage of nonpreferred drugs for higher co-pays.

PREMIUM
A monthly fee paid by consumers to be part of a Part D plan.

PRIOR AUTHORIZATION
An approval process required by some plans before they will authorize coverage of certain drugs.

STANDALONE PLAN
A drug plan that is only offering prescription drug coverage under Part D. Participants receive doctor and hospital coverage through another Medicare plan or through traditional Medicare.

STEP THERAPY
A process that requires a lower-cost, therapeutically equivalent drug to be dispensed and proved ineffective before a higher-cost drug will be covered.

SUBSIDIES
Assistance available to certain low-income Medicare beneficiaries to pay all or part of their cost of enrolling in Part D.

TIERED CO-PAYS
Different cost-sharing amounts for therapeutically equivalent drugs.

First published on November 12, 2006 at 12:00 am
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