2025 Medicare Glossary

Prescription Drug Plan Terms and What They Mean

A – D | E – H | I – L | M – P | Q – T | U – Z

Emergency:

A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life (and if you are a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a limb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Evidence of Coverage (EOC) and Disclosure Information:

This document, along with your enrollment form and any other attachments which explain your coverage, defines our obligations and explains your rights and responsibilities as a member of our Plan.

Exception:

A type of coverage decision that, if approved, allows you to get a drug that is not on our formulary (a formulary exception), or get a non-preferred drug at a lower cost sharing level (a tiering exception). You may also request an exception if our plan requires you to try another drug before receiving the drug you are requesting, if our plan requires a prior authorization for a drug and you want us to waive the criteria restriction, or if our plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Explanation of Benefits (EOB):

An explanation of benefits (commonly referred to as an EOB) is a statement sent by the plan to members explaining what prescription drug services were paid for on their behalf and any costs that the member is responsible for. The EOB is not a bill.

Extra Help:

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and cost-sharing.

Generic Drug:

A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a generic drug works the same as a brand name drug and usually costs less.

Grievance:

A grievance is a complaint or dispute (other than a coverage or payment dispute) expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested.