Glossary & Helpful Contacts

Coinsurance

When you and your insurance plan share the cost of care based on a percentage. For example, a plan might pay 80% of the cost for a service and you pay the remaining 20%. Percentages vary by plan and service.

Copayment (Copay)

When you and your insurance plan share costs based on a flat dollar amount that you pay. For example, at an office visit or a pharmacy, you may be asked to pay a $10 or $20 “copay” or other flat fee.

Deductible

The amount you must pay each year for health care or prescriptions before your insurance begins to share costs with you.

Drug Coverage Phases

Under Part D, your coverage is divided into three cost-sharing phases: Deductible Phase, Initial Coverage Phase, and the Catastrophic Coverage Phase. Learn more about Drug Coverage Phases

Drug Formulary

A list of prescription drugs covered by a health insurance plan.

Drug Sources

A drug source is simply where you fill your prescriptions. Your drug costs will vary depending on whether you fill your prescriptions at a network pharmacy with standard or preferred cost sharing or through the CVS Caremark mail order service.

Drug Tiers

Part D prescription drugs are divided into pricing tiers. Depending on the tier and coverage phase, your drug costs will be a fixed amount (copay) or a percentage of the total cost (coinsurance). View your plan's Drug Tiers

HMO (Health Maintenance Organization)

A type of Medicare Advantage plan that generally requires the use of in-network providers except for urgent/emergency care.

HMO-POS (Health Management Organization with Point of Service)

A type of Medicare Advantage plan with lower costs for in-network services and the option to use out-of-network providers for some services at a higher cost.

LPPO (Local Preferred Provider Organization)

A type of Medicare Advantage plan with a network of preferred providers and the option to see out-of-network providers, usually at a higher member cost.

Maximum Out of Pocket

The total amount that you will have to pay “outof-pocket” each year for hospital and medical copays and coinsurances for covered services before your insurance will start paying 100% of these costs for covered services.

NOTE: Monthly premiums and prescription drug costs are not included when figuring out-of-pocket costs.

Medigap/Medicare Supplement

Medigap, also known as Medicare supplement insurance, is a supplemental health insurance policy sold by private companies to help cover out-of-pocket costs incurred under Original Medicare. It's designed to fill the "gaps" in Original Medicare coverage, which doesn't have a limit on out-of-pocket expenses. Essentially, it provides additional coverage for costs like deductibles, co-payments, and co-insurance related to services covered by Original Medicare.

Medicare Advantage

Medicare Advantage, also known as Medicare Part C, is a program that allows individuals to receive Medicare benefits through private health plans. These plans, approved by Medicare, cover the same services as Original Medicare (Parts A and B) and may also include additional benefits like prescription drug coverage (Part D), dental, vision, and hearing care.

Medicare Part A

Medicare Part A, also known as Hospital Insurance, helps cover inpatient care in hospitals, skilled nursing facilities, hospice care, and some home health care.

Medicare Part B

Medicare Part B, also known as medical insurance, is a voluntary part of Medicare that helps cover medically necessary services from doctors and other health care providers, outpatient care, home health care, and some durable medical equipment. It also covers certain preventive services.

Medicare Part C

Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Parts A and B) that provides coverage through private companies. These plans must offer at least the same coverage as Original Medicare, but they may also include additional benefits and may have different rules and costs.

Medicare Part D

Medicare Part D is the part of Medicare that provides prescription drug coverage for those with Medicare. It's an optional, supplemental coverage offered by private insurance companies approved by Medicare. Part D plans are designed to help reduce the cost of prescription medications.

Network

A set of health care providers who are contracted to provide health care services to patients with a particular health insurance plan. Providers can be in- or out-of-network. Search out Network of 15,000 Providers

Original Medicare

A government-funded health insurance program for individuals 65 and older (and some younger individuals with disabilities).

Premium

The amount you pay to the government or to an insurance company each month/quarter in order to have health or prescription drug coverage.