Glossary of Terms used in Part D discussions

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Administration on Aging: The Older Americans Act of 1965 established the AoA, which is an agency of the U.S. Department of Health and Human Services. Its mission is to develop a comprehensive, coordinated and cost-effective system of long-term care that helps elderly individuals to maintain their dignity in their homes and communities.

Advocate: A person who gives you support or protects your rights.

AEP or "Annual Election Period": The annual period from November 15 until December 31 when a Medicare beneficiary can enroll into a Medicare Part D plan or re-enroll into their existing Medicare Part D Plan or change into another Medicare Part D plan. Beneficiaries can also switch to a Medicare Advantage Plan that also has a Prescription Drug plan (MA-PD). The chosen Medicare Part D plan coverage begins on January 1st. Related to this word are IEP, OEP, and SEP.

Annual Notice of Change: This is a notice provided by the insurance company that explains which benefits have changed and how they have changed for the upcoming plan year. It is a notice required by the Centers for Medicare and Medicaid Services (CMS).

Appeal: An appeal is a special kind of complaint you can make if the plan declines to cover prescription drugs you want or refuses to pay for drugs you've already received. You can also appeal if your plan decides to stop covering drugs you're currently receiving. There is a specific process you and your prescription drug plan must use when you appeal one of its decisions.

Assets: Property you own that the government may review when you apply for assistance. For help with the costs of a Medicare prescription drug plan, the government counts cash or any property that can be turned into cash within 20 days. This includes checking and savings accounts, certificates of deposit, IRAs and 401(k) plans, stocks, bonds, and similar items. It does not include your primary home, or certain property related to burial expenses.

Authorized Representative: The person you designate to assist or handle affairs related to your health care services. This may be someone you designate as a Power of Attorney, a family member, friend, caregiver, or it may be an advocate you assign to assist with an exception, appeal or grievance.

Base Beneficiary Premium: The base beneficiary premium is the premium amount set by the Centers for Medicaid and Medicare Services annually as being the average premium available from PDP plans nationally. This amount may be more or less than the premium amount set for the PDP plan you select.

Beneficiary: The person, persons or entity designated to receive benefits from an insurance policy.

Benefit: Another name for coverage. For example, in a Medicare Part D plan, prescription drug costs that are paid for by your insurance plan are your benefits, or coverage.

Benefit Percentage: Percentage of covered expenses the plan pays after the deductible.

Benefit Period: A benefit period begins the first day you stay in a hospital or skilled nursing facility and ends when you have been out of the hospital or skilled nursing facility for 60 days in a row. If you go into the facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.

Bonus Drug List: An additional list of commonly used prescription drugs that are not covered by Medicare Part D like Alphrazolam, Lorazepam, and Temazepam, but are included in the UnitedHealth Rx plans.

Brand Name Drugs: Pharmaceutical companies hold patents on the drugs that they develop for a certain amount of time, these drugs are sold under a trademarked brand name.

(CMS) Centers for Medicare and Medicaid Services: The federal agency overseeing both the Medicare and Medicaid programs. They were made responsible for carrying out the legislation that put the Part D insurance plans into existence and overseeing how all of the plans conduct business.

Cancellation: Termination of a policy before its normal expiration date.

Caregiver: A person who helps care for someone who is ill, disabled or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide caregiving services for a fee.

Catastrophic Coverage: This is the last portion of coverage in a Part D plan in which the plan pays almost the entire drug expense for the remainder of the calendar year. The portion that the beneficiary pays during this step is a very small amount of the drug expenses (approximately five percent).

Catastrophic Limit: The catastrophic limit is the highest amount of money you’ll have to pay out of your own pocket in a year for certain covered prescription drug charges.

Certificate of Insurance: The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what is covered, what is not, and insurance limits.

Chronic Condition: Prolonged conditions or illness, such as heart disease, asthma, diabetes.

Claim: A request by an beneficiary (or their provider) to the insurance company for the insurance company to pay for services obtained from a health care professional.

Coinsurance: The portion of cost belonging to the beneficiary after costs are split on a percentage basis. In a 20/80 plan, the beneficiary would pay 20%.

Coinsurance Out-of-Pocket Maximum: After this maximum is met, the plan pays 100% of covered expenses.

Co-payment or Co-pay: When the beneficiary pays a pre-determined, flat amount for each service. A doctor's visit copay is often ten or fifteen dollars.

COBRA: A Federal law that gives the right to pay for continued group health care coverage for a specified period if the person loses coverage because of reduced work hours or leaving or loss of a job.

Coordination of Benefits: This occurs when the insured is covered under more than one plan (for example under a group plan at work, and as a family member on a spouse's plan) the benefits from the plans are coordinated so as to limit the total benefits from all plans. Usually, the benefits from all plans will not exceed 100% of the covered medical expenses.

Cost Sharing: The way in which insurance plans share their costs. Examples of cost sharing are co-insurance and co-payments.

Coverage: The benefits package received from an individual insurance plan. Under Part D, prescription drug costs paid by the insurer are the benefits package, also known as coverage.

Coverage Gap: The gap in your coverage that spans between ordinary drug coverage and catastrophic drug coverage. In this gap, the Medicare beneficiary pays 100% of their prescription costs. According to the federal government, about 88% of Medicare beneficiaries who enrolled in a Medicare Part D plan do not have Donut Hole (or doughnut hole) coverage. The standard or model Part D coverage begins with a deductible of $295 followed by a co-pay of 25% on the next $2405 (you pay $601.25). Upon reaching the total medication costs of $2700 (with $896.25 out of pocket), coverage ceases and the beneficiary is 100% responsible for all costs during a "blackout period" known as the "Donut Hole" or "Coverage Gap", until a new spending tier, an additional $3453.75 out of pocket, is reached and coverage kicks in again at the "Catastrophic" level. See Doughnut (Donut) Hole.

Creditable coverage: A plan other than a Part D plan that offers Prescription drug coverage and which meets certain Medicare standards.

Deductible: The amount that the beneficiary must pay first, before coverage from the plan makes any of the payments. In Part D this is usually the first $295 of eligible drug expenses for the year.

Disability Benefit: A feature of some policies for the waiver of premium if the policyholder becomes permanently and totally disabled.

Disenroll: When you disenroll, you end your coverage in a prescription drug or other health plan. Your plan can choose to disenroll you under specific circumstances.

Doughnut (donut) Hole: The gap in your coverage that spans between ordinary drug coverage and catastrophic drug coverage. In this gap, the Medicare beneficiary pays 100% of their prescription costs. According to the federal government, about 88% of Medicare beneficiaries who enrolled in a Medicare Part D plan do not have Donut Hole (or doughnut hole) coverage. The standard or model Part D coverage begins with a deductible of $295 followed by a co-pay of 25% on the next $2405 (you pay $601.25). Upon reaching the total medication costs of $2700 (with $896.25 out of pocket), coverage ceases and the beneficiary is 100% responsible for all costs during a "blackout period" known as the "Donut Hole" or "Coverage Gap", until a new spending tier, an additional $3453.75 out of pocket, is reached and coverage kicks in again at the "Catastrophic" level. See Coverage Gap.

Dual Eligibles: People eligible for both Medicare and Medicaid.

Effective Date: The date your insurance is to actually begin. You are not covered until the policies effective date.

Eligible Drugs: A list of prescription drugs that are covered by a particular Part D plan. Drugs listed on the formulary are also called eligible drugs. A formulary can also be called a preferred-drug list (PDL), or a select drug list.

Eligibility for the Medicare Prescription Drug Program: You're eligible for the Medicare Prescription Drug Program if you're eligible for Medicare benefits under Part A or enrolled in Part B and live in the service area of the plan.

Enrollment Period: The period during which individuals may enroll for an insurance policy, Medicare, HMO benefits. For Medicare Part D, there are different "enrollment periods", the IEP, AEP, OEP, and SEP.

Exclusions: Items not covered by an insurance policy. Part D drug plans have two types of exclusions. The first type is the drugs that Medicare has excluded from coverage under Part D, no Part D plan will cover these. The second type is the drugs excluded from a particular plan's list of covered drugs, or formulary, this list varies by Part D plan.

Explanation of Benefits: The insurance company's explanation of its decision regarding your claim.

Food and Drug Administration: The FDA oversees approval and regulation of all prescription drugs, both brand-name and generic. Its goals include safety, efficacy and quality.

Free Examination Period: is also known as a "free-look." It is the time period after an insurance policy is delivered during which you can decide whether to keep it or return it to the company for a full refund of the initial premium.

Free Look: This is also known as a "free examination period." It is the time period after an insurance policy is delivered during which you can decide whether to keep it or return it to the company for a full refund of the initial premium.

Formulary: A list of prescription drugs that are covered by a particular Part D plan. Drugs listed on the formulary are also called eligible drugs. A formulary can also be called a preferred-drug list (PDL), or a select drug list.

Generic Drugs: Prescription drugs that have the same active ingredient formula as a brand name drug. Generic drugs usually cost lessa fraction of their brand name counterpart. They are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Grievance: A grievance is a complaint about the way your prescription drug plan is providing services. For example, you may file a grievance if you have a problem calling the plan or if you're unhappy with the way a plan employee acted. You wouldn't file a grievance to complain about a treatment decision or a service that is not covered, you would file an appeal.

Group Insurance: Coverage through an employer or other entity that covers all individuals in the group.

Guaranteed Renewable: An agreement by an insurance company to insure a person for as long as premiums are paid.

HMO: A Health Maintenance Organization that is contracted with CMS 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.

Health Insurance Portability & Accountability: Act A law passed in 1996, HIPAA is also called the "Kassebaum-Kennedy" law. It expands your health care coverage if you have lost your job and protects you and your family from discrimination based on past or present health conditions.

Health Savings Account (HSA): An account held in trust for the account holder. The employer or employee makes annual tax-free contributions to the account that must be maintained in conjunction with a high deductible health insurance policy.

IEP or "Initial Enrollment Period": The period we just went through in 2005-2006 and covered November 15, 2005 until May 15, 2006. The IEP provided the initial opportunity for existing Medicare recipients to enroll into the Medicare Part D plans. Please note, for those persons who had already qualified for Medicare, the IEP also acted as the first AEP or Annual Election Period (see below). If you enrolled in the IEP, you should have received coverage beginning the first of 2006 (if you enrolled in 2005) or the first day of the month after your enrollment in 2006. For those persons who are just turning 65 or just becoming eligible for Medicare, the Initial Enrollment Period (IEP) is a seven (7) month period that extends three (3) months before the month when a person reaches 65, plus the month where the person turns 65, plus the three (3) month period after the person turns 65. (Please note this is the same 7 month period during which a beneficiary can also enroll in the Medicare Part B program). If you enrolled in the months before turning 65, your Part D policy begins the first day of your birthday month. If you enrolled during or after your birthday month, your Part D plan begins the first day of the next month. Eligible Medicare Part D beneficiaries who did not enroll during their IEP now face a life-time monthly premium penalty. Related to this word are AEP,OEP,and SEP.

In-Network: Providers or health care facilities which are part of a health plan's network of providers with which it has negoiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.

Individual Health Insurance: Health insurance coverage on an individual, not group, basis.

Identification Card: Card issued by your insurance company to indicate your policy number and coverage.

Initial Coverage Limit: Amount you pay for Medicare prescription drug coverage, with a PDP or an MA-PD, after you have paid the annual deductible (if applicable) and until the total covered prescription drug costs paid by you and the plan add up to $2700.

Lapsed Policy: A policy that has terminated because of failure to pay the premium(s).

Late Enrollment Fee: In an attempt to encourage as many eligible people as possible to enroll in a Part D prescription drug plan before the first enrollment period ended in May 2006, or to enroll as soon as they become eligible for Medicare, Congress created a late enrollment fee. This fee is equal to about one percent of the Medicare Part D premium for each month's delay in enrolling. This is an unlimited percentage, lasting as long as you are enrolled in a Part D prescription drug plan.

Lifetime Maximum: The total dollar amount the plan will pay for all types of medical expenses, for all benefit periods, while the insured person is alive and covered under the plan.

Limitation: The conditions or circumstances for which benefits are limited or are not payable.

Long-Term Care Policy: Insurance policies that cover specified services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include nursing care, home health care services, and custodial care.

Loss: The basis for a claim under an insurance policy.

Low-Income Assistance: Low-income assistance helps people whose incomes are limited. For the Medicare Prescription Drug Program, if your income is below 135 percent of the federal poverty level and your assets are also limited, you'll pay no monthly premium, no deductible and have no gap in coverage.

MA / MA-PD: Medicare Advantage Plans (MAs) and Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs) are private plans that provide doctor and hospital services in place of Medicare and Medicare pays these private companies to manage the healthcare instead of paying for the beneficiary claims directly. Examples of MAs or MA-PDs that administer your Medicare Part A and Part B, as well as possibly providing Prescription Drug coverage are: Health Maintenance Organizations (HMOs), Private, Fee for Service Organizations (PFFS), or Preferred Provider Organizations (PPOs). Typically, the MA-PDs also provide additional value-added service to its Members such as additional covered days in the hospital. If you purchase a MA-PD plan, you do not need to purchase a PDP plan (see above) nor do you need a Medicare Supplement.

Mail-Service Pharmacy: Mail-service pharmacies are used by many plans as a cost-saving and convenient alternative to retail pharmacies. Members typically order their drugs by phone, fax, email or Internet. Most prescription orders are filled and received by members in two to four days. Here's a look at how you'll save when you use our Preferred Mail Service to order a 90-day supply of a drug.

Managed Care: A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services.

Maximum Dollar Limit: The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.

Medicaid: A federal medical assistance program that covers certain individuals and families meeting low income guidelines. Medicaid is jointly funded by the federal and state governments to assist the states in providing long-term care assistance to people who meet certain eligibility criteria.

Medicare Advantage Plans: Health plans offered by private insurance companies that contract with Medicare to provide Medicare coverage. Depending on where the beneficiary lives, Medicare Advantage Plans may be available both with and without Part D plans. Medicare Advantage Plans are also called Medicare Health Plans. The Medicare Advantage Plans used to be called the Medicare+Choice plans.

Medicare: The health insurance program run by the federal government for people age 65 and older, people with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplant).

Medicare Part D Prescription Drug Plan: Insurance plans offering prescription drug coverage that meets the standards established by Medicare. Other Names for these plans include Part D prescription drug plans, PDPs, or MA-PDs. However, not all private insurance plans offering prescription drug coverage are Part D plans. You'll want to pay close attention to whether a plan is a Part D plan.

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

Medicare Prescription Drug, Improvement and Modernization Act of 2003: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 is a federal law that brought the most dramatic changes to the Medicare program since it began in 1965. These changes include more affordable health care, prescription drug coverage to all people with Medicare, expanded health plan options, improved health care access for rural Americans, and preventive care services, such as flu shots and mammograms.

Medicare Supplements: Medicare Supplements or MediGap Plans provide additional coverage to your Original Medicare plans (Medicare A and B). For instance, Medicare Supplements will pay a portion of your Medicare Co-insurance. There are a series of Medicare Supplements that provide a variety of coverage options at varying premiums. Stand-alone Prescription Drug Plan (PDP) can be used together with your Medicare Supplements. A Medicare Advantage Plan (MA or MA-PD) connotbe used with a Medicare Supplement.

Medigap: See Medicare Supplements

Network: The doctors, hospitals, and pharmacies having contracts with an insurance plan to provide care to the plan's members. It is necessary to use your Part D prescription drug plan's network of pharmacies to save money on your drugs.

Network Retail Pharmacy: A network retail pharmacy is a pharmacy that's part of a group of pharmacies chosen by a prescription drug plan to provide pharmacy care to its members at a lower cost.

Non-Formulary Drugs: Non-formulary drugs are prescription drugs that aren't included on a prescription drug plan's formulary - or list of approved drugs.

Non-Preferred Brand Name Drugs: A non-preferred brand-name drug is a prescription medication that is covered by a prescription drug plan, but will cost a member more than a preferred brand-named drug. A non-preferred brand-name drug is in a higher cost formulary tier than a preferred brand-name drug.

Non-Renewal: The termination of the insurance contract by electing not to renew the policy at the anniversary date.

OEP or "Open Enrollment Period": Running from January 1 until March 31, Medicare beneficiaries can make additional choices regarding Medicare Advantage plans. Medicare beneficiaries who have both Medicare A and Medicare B, and who have enrolled in a Medicare Part D plan (PDP) can switch to a Medicare Advantage plan (MA-PD) - Please note however, in the OEP, you may not move to another stand alone PDP. Medicare Beneficiaries who already have a MA-PD can switch to another MA-PD or they can switch back to traditional Medicare and a stand-alone PDP. MA-PD members are not allowed to switch to a MA plan without a prescription drug plan. If a Medicare Beneficiary is in a MA plan without prescription drug coverage, they are not able to switch to a MA-PD (Medicare Advantage plan with prescription drug coverage). Related to this word are AEP, IEP, and SEP.

Original Medicare: The term "Original Medicare" is often used to describe your normal Medicare A and B benefits. If you have Medicare Part A and/or B coverage you can purchase a Medicare Part D (PDP) plan. If you have Medicare A and B you can also purchase a Medicare Supplement to cover a portion of the costs not covered by Original Medicare or you can enroll in a Medicare Advantage Plan (with or without Prescription Drug coverage).

Out-of-Network Benefit: Generally provides a beneficiary with the option to access plan services outside of the contracted provider network. In some cases, a beneficiary's out-of-pocket costs may be higher for an out-of-network benefit.

Out-of-Pocket Costs: The amounts the beneficiary pays as their share of prescription drug costs in a Part D plan. Deductibles, co-insurance, and the amounts paid during the doughnut (donut) hole or "coverage gap" make up the total out-of-pocket costs. The out-of-pocket costs are called "true out-of-pocket costs," or "TROOP." When each beneficiary "true out-of-pocket costs" exceed $4350, they are eligible for the catastrophic coverage step of a Part D plan.

Outpatient Services: Services that do not take place as an in-patient in the hospital. They may be provided in clinics or provider officers, ambulatory surgical centers, hospices, home health services, and so forth.

Outpatient Services Maximum:Outpatient Services: The annual maximum amount the plan pays toward outpatient services.

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.

Quantity Limits: For some medications, the insurer may limit the number of tablets or units that you can receive per month. These guidelines are based on maximum dosages recommended by the FDA.

Reinstatement: Resumption of coverage under a policy that has lapsed because of nonpayment of the premium after the grace period has ended.

Risk: The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications' side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice.

RX: A symbol for "prescription drugs".

SEP or "Special Election Period": The time period granted to Medicare beneficiaries who are allowed to change plans outside of the normal AEP. Examples of people who are granted a SEP are: Medicaid recipients (dual-eligibles), Victims of Hurricane Katrina, or Medicare beneficiaries who are no longer part of a creditable prescription drug plan (such as when their individual plan no longer exists). When someone involuntarily loses their existing benefits, they have a 60 day SEP during which they are able to enter into another Medicare Part D plan. Also, if someone moves out of the service area of their plan (for instance, moving to another state), they will have a 60 day SEP after the move during which they can re-enroll into a Medicare Part D plan. Related to this word are AEP,IEP, and OEP.

Short-Term Disability: An injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual's full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.

Short-Term Medical: Temporary coverage for an individual for a short period of time, usually from 30 to 365 days.

Skilled Nursing Facility: A facility that provides inpatient skilled nursing care, rehabilitation services or other related health services. "Skilled nursing" does not include a convalescent home or custodial care.

State Pharmaceutical Assistance Programs (SPAP): State pharmaceutical assistance programs help cover the prescription drug costs of elderly people with low incomes or people with disabilities who don't qualify for Medicaid. Currently, 39 states offer some type of program to provide prescription drug coverage or assistance. Most programs use state funds to subsidize a portion of the costs for people who qualify.

Step Therapy (step edits): In some cases, you're required to first try certain drugs to treat your medical condition before the plan will cover another drug for that condition. You and your doctor must work with the plan to ensure coverage. These drugs are designated 'ST' in the formulary.

Stop-Loss: The dollar amount of claims filed for eligible expenses at which which point you've paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.

Tier: A formulary is often divided into tiers. Each tier represents a different level of cost-sharing for prescription drugs. As the tiers rise, members pay more for the listed drugs. For example, a tier-1 drug may cost you a $7.50 copay, and a tier-3 drug may cost you a $50 copay. UnitedHealth Rx plans have four tiers, and your cost-sharing amount depends on which tier your drug is listed under.

TrOOP - True Out-of-Pocket: True out-of-pocket costs. Those costs you pay for which you are not reimbursed.

Underwriting: The insurance company's process for determining whom it will insure.

Usual, Customary & Reasonable (UCR): The dollar amount the insurance companies believe to be a fair price for the medical service/procedure in a specific geographic area. Companies have developed their own UCR, which often do not reflect the doctor's actual bill. If the doctor's chargers are higher than the companies UCR charge, you generally have to pay the balance.

Veterans Administration (VA): The VA is the federal agency that oversees all programs and benefits available to military veterans.

Waiting Period:This has two meanings: (1) the time period you must wait before you can get health insurance from a new employer; and (2) the time that must pass after becoming insured before the policy will begin to pay benefits for a pre-existing condition or specified illness.

Waiver: An amendment to a policy that excludes coverage for certain medical conditions.