2023 Medicare Glossary
Prescription Drug Plan Terms and What They Mean
Medicare Part D plans may limit the number (or amount) of drugs covered within a certain time period. It is possible for your physician to contact the plan and ask for an exception to the Quantity Limits.
Although Medicare is a Federal program, Blue MedicareRx (PDP) is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. Our service area includes these states: Central New England (Connecticut, Massachusetts, Rhode Island and Vermont).
Special Election Period (SEP):
CMS will grant a special enrollment period if certain circumstances apply, such as moving to a new state, and entering or leaving a skilled nursing facility. During this time you may enroll or disenroll from a prescription drug plan.
High cost injectable and/or oral medications used to treat complex or rare conditions such as rheumatoid arthritis, multiple sclerosis, hepatitis C and cancer.
Standard Cost-sharing Pharmacy:
There are more than 63,000 participating pharmacies in Blue MedicareRx's network. These pharmacies contract with us to provide your prescription drug benefits. The network includes many neighborhood retail pharmacies and a convenient mail service pharmacy. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
State Pharmacy Assistance Program (SPAP):
State Pharmaceutical Assistance Programs (SPAPs) are state-run programs that assist low-income seniors and adults with disabilities in paying for their prescription drugs. SPAP coverage varies by state, but the programs generally provide Part D “wraparound” coverage, meaning that they pay costs that Medicare Part D does not pay.
Step therapy is an approach to treatment intended to control the costs and risks posed by prescription drugs. The practice begins medication for a medical condition with the safest and most cost-effective drug therapy and progresses to other more costly or risky therapies only if necessary.
Supplemental Security Income (SSI):
Supplemental Security Income (SSI) is a government program that provides stipends to low-income people who are either aged (65 or older), blind, or disabled. Although administered by the Social Security Administration, SSI is funded from the U.S. Treasury general funds, not the Social Security trust fund.
Drug tiers are how we divide prescription drugs into different levels of cost. Drugs in lower tiers will be your cheapest options. Drugs in higher tiers will be the most expensive.
True Out-Of-Pocket (TrOOP) cost:
True out-of-pocket (TrOOP) costs are the payments that count toward a person's Medicare drug plan out-of-pocket threshold of $7,400 (for 2023). TrOOP costs determine when a person's catastrophic coverage will begin. The drug plan keeps track of each member's TrOOP costs.