Annual Notice of Change (ANOC): A required notification that is mailed to members each October telling them what will be changing in their Blue MedicareRxSM benefits as of the new calendar year.
Catastrophic coverage: Once a member has paid their total true out-of-pocket costs (TrOOP) within in a calendar year (in 2009, the TrOOP level is $4,350 in total member payments), then the coverage will change to catastrophic coverage. At this level the member pays either a reduced copay or five percent, whichever is greater.
Coverage gap: A level of benefits where the member may be required to pay most or all of their drug costs. (Please note that the current Blue MedicareRx plan offered by blue-medicarerx does not have a coverage gap (also known as the "donut hole"))
Creditable coverage: A plan that is equivalent to Medicare's standard Part D coverage is considered "creditable coverage." All approved Medicare Part D plans meet minimum creditable coverage standards.
Dispense as written (DAW): Physician notation to the pharmacist that a generic equivalent should not be dispensed. Only the physician may make this indication.
Evidence of Coverage (EOC): A detailed booklet that is mailed each October with the plan's benefits as of the new calendar year.
Explanation of Benefits (EOB): An explanation of a claim, including what was paid and the member's liability. For the Part D benefits, Initial coverage period, true out-of-pocket costs (TrOOP), coverage gap, and catastrophic levels are tracked, regardless of benefit design.
Generic substitution: Massachusetts requires pharmacies to dispense the generic version of a prescription (when available) unless the physician indicates that no substitutions can be made.
Initial coverage period: The initial payments of the plan as calculated by drug costs and the member's deductibles, copays, or co-insurance. (This level is $2,700 for 2009.)
Late enrollment penalty (LEP): A penalty added to a member's premium if they did not have creditable prescription coverage for more than 63 days any time after May 2006.
Low-income subsidy (LIS): A program for those members below certain income levels to receive reduced premium rates and reduced copayments on the Part D portion of the plan.
Part D plan (PDP): A regulated, insured Part D plan, which offers prescription drugs only (i.e., no medical benefits).
Prior authorization: An approval needed from the Part D carrier prior to a prescription being dispensed to the member. The approval form must be submitted by the prescribing physician.
Quality Care Dosing (QCD): The limit on the number of doses of a particular prescription drug that may be dispensed within a set time period.
Service area: The geographic area a member may reside in to be eligible for a plan.
Step therapy: A requirement to try a less expensive, first-line medication prior to a second-line or brand-name medication.
True out-of-pocket (TrOOP): The total out-of-pocket costs the member pays for the calendar year. This dollar figure is tracked once catastrophic coverage is reached.
