2025 Medicare Glossary

Prescription Drug Plan Terms and What They Mean

Manufacturer Discount Program:

A program under which drug manufacturers pay a portion of the plan’s full cost for covered Part D brand name drugs and biologics. Discounts are based on agreements between the Federal government and drug manufacturers.

Medicaid (or Medical Assistance):

Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Some people with Medicare are also eligible for Medicaid. In addition, there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, such as their Medicare premiums. To find out more about Medicaid and its programs, contact the Medicaid Agency in your state using the contact information in the Appendix of the Evidence of Coverage (EOC).

Medicare:

The federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).

Medicaid (or Medical Assistance):

A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. State Medicaid programs vary, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medically Accepted Indication:

A use of a drug that is either approved by the Food and Drug Administration or supported by certain references, such as the American Hospital Formulary Service Drug Information and the Micromedex DRUGDEX Information system.

Medicare Advantage (MA) Plan:

Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be i) an HMO, ii) a PPO, iii) a Private Fee-for-Service (PFFS) plan, or iv) a Medicare Medical Savings Account (MSA) plan. Besides choosing from these types of plans, a Medicare Advantage HMO or PPO plan can also be a Special Needs Plan (SNP). In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage.

Medicare Prescription Drug Coverage (Medicare Part D):

Insurance to help pay for outpatient prescription drugs, vaccines, biologics, and some supplies not covered by Medicare Part B.

Member (Member of our Plan, or “Plan Member”):

A person with Medicare who is eligible to get covered services, who has enrolled in our Plan, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Network Pharmacy:

Pharmacies, including retail, mail-order, and institutional pharmacies, under contract with a Part D sponsor to provide covered Part D drugs at negotiated prices to Part D enrollees.

Original Biological Product:

A biological product that has been approved by the Food and Drug Administration (FDA) and serves as the comparison for manufacturers making a biosimilar version. It is also called a reference product.

Original Medicare ("Traditional Medicare" or "Fee-for-Service" Medicare):

Original Medicare is coverage managed by the federal government. Generally, there's a cost for each service. Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.

Out-of-Network Pharmacy:

A licensed pharmacy that is not under contract with a Part D sponsor to provide negotiated prices to Part D plan enrollees.

Out-of-Pocket Costs

See the definition for cost sharing above. A member’s cost sharing requirement to pay for a portion of drugs received is also referred to as the member’s out-of-pocket cost requirement.

Out-of-Pocket Threshold:

The maximum amount you pay out of pocket for Part D drugs.

Over-the-Counter Medicines (OTC Medicines):

Medicines that do not require a prescription.

Part D:

The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

Part D Drugs:

Drugs that can be covered under Part D. We may or may not offer all Part D drugs. Certain categories of drugs have been excluded as covered Part D drugs by Congress.

Preferred Cost-sharing:

Preferred cost sharing means lower cost sharing for certain covered Part D drugs at certain network pharmacies.

Premium:

A payment for health or prescription drug coverage that is made to your plan or Medicare.

Prescription Drug Plan (PDP):

A prescription drug plan, an MA-PD plan, a PACE Plan offering qualified prescription drug coverage, or a cost plan offering qualified prescription drug coverage.

Prior Authorization:

Approval in advance to get certain drugs. Covered drugs that need prior authorization are marked in the formulary and our criteria are posted on our website.