Part D Terminology

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Across
  1. 2. A type of insurance in which the insured pays a share of the payment made against a claim.
  2. 3. A group of medications used to treat the same condition or diagnosis.
  3. 5. A requirement to contact the plan before filling certain prescriptions. Prescribers may need to show that the drug is medically necessary for the plan to cover it.
  4. 6. An 11-digit identification number assigned to all drug products.
  5. 8. A one-time, 30-day supply of a drug that Medicare drug plans must cover when an individual is in a new plan or when their existing plan changes its coverage.
  6. 10. A drug sold directly to a consumer without the need for a prescription from a healthcare professional.
  7. 12. The deductible is the amount paid out of pocket by the policy holder before an insurance provider will pay and expenses.
  8. 13. This team generally reviews the pre-authorization requests from members and providers coordinating how much care people get. The goal is to make sure that patients get the care they need without wasting resources.
  9. 14. A drug that is sold under a specific name or trademark that is protected by a patent.
  10. 16. A list of prescription drugs a plan covers and at what tier.
  11. 17. A drug plan formulary that divides drugs into groups.
  12. 19. A drug that is changed by combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient.
  13. 22. True Out of Pocket. The amount members pay toward the cost of their prescription drugs including deductible, copays, and coinsurance (but not including premiums).
  14. 23. A statement sent to a member which gives all of the details on what the plan covered, did not cover, how much money needs to be paid, and more. The EOB is generated when your provider submits a claim for the services the member received.
  15. 24. A process where members must first try a less expensive drug to see if it works before the plan will agree to cover a more expensive drug.
Down
  1. 1. Drugs and medications that by law require a prescription.
  2. 4. Drugs considered to have a strong potential for abuse or addiction, but have a legitimate medical use.
  3. 7. A generic drug is a pharmaceutical drug that contains the same chemical substance as a brand name. Sale of these drugs are allowed once the patent on the original brand drug expires.
  4. 9. The formulary is usually divided into tiers or levels of coverage based on the type or usage of the medication. Each tier has a defined out-of-pocket cost that the patient must pay before receiving the drug.
  5. 11. The price members pay for a policy, usually as a monthly payment.
  6. 15. A document that describes in detail the health care benefits covered by the health plan. It provides documentation of what that plan covers and how it works, including how much the member pays.
  7. 18. A restriction on the amount or quantity of medication this is covered by the plan during a specific period of time.
  8. 20. A payment made by a member in addition to that made by an insurer.
  9. 21. Cost sharing occurs when patients pay for a portion of health care costs not covered by health insurance.