|AAA - Area Agency on Aging |
ADAP - AIDs Drugs Assistance Program
AMH - Addictions and Mental Health Division
Auto-enrollment - CMS randomly assigns dual eligible individuals into Prescription Drug Plans (PDPs).
Benchmark plan - A prescription drug plan with a monthly premium at or below the low income premium subsidy amount.
Biological - Usually a drug or vaccine made from a live product and used medically to diagnose, prevent, or treat a medical condition (e.g. flu or pneumonia shot).
BOB - Benzodiazepines, OTC drugs, Barbiturates
Catastrophic Coverage - The highest amount of money paid out-of-pocket before a health plan pays the majority or all copay amounts. Medicare Part D catastrophic coverage begins at $3,600 out-of-pocket and $5,100 in total drug costs (total drug costs include what the beneficiary and other payers have paid).
Clawback - The calculated amount that the state government pays the federal government to provide the Medicare Part D drug benefit.
CMS - Centers for Medicare and Medicaid Services
Coinsurance - A fixed percentage paid per prescription per fill.
Compound Drugs - Two or more drugs added together by a pharmacy.
Copayment (copay) - A fixed amount paid per prescription per fill.
Cost-sharing Tier - Different levels of copay amounts depending on the type of drug. The lowest copay is for generics, followed by formulary brands, and a non-formulary copay is in the highest tier.
Creditable Coverage - Creditable coverage means an insurance policy that is as good or better than a Part D plan. (e.g. retiree drug coverage).
|DD - Developmentally Disabled |
Deemed - Any individual considered automatically eligible for extra help with the Medicare Part D drug benefit (this includes individuals with Medicaid, a Medicare Savings Program, or SSI).
DHS - Department of Human Services
DMAP - Office of Medical Assistance Programs
Dual Eligible - A person who has Medicare and Medicaid
EOPC - Eastern Oregon Psychiatric Center
EOTC - Eastern Oregon Training Center
FCHP - Fully Capitated Health Plan (These are the Medicare Managed Care organizations that provide health coverage for OHP clients).
Formulary - A formulary is a list of drugs that a health plan will cover. Formulary drugs usually have lower copays than non-formulary drugs. A formulary is also known as a Preferred Drug List.
FPL - Federal Poverty Level
Generic drugs - A drug which is exactly the same as a brand name drug and which may be manufactured and marketed after the brand name drug. Generic drugs cost significantly less than brand name drugs.
|LIS - Low Income Subsidy. The LIS program is operated by SSA and provides extra help with prescription drug costs for individuals who meet the income and asset requirements. |
LTC - Long Term Care
MA - Medicare Advantage plans (currently known as Medicare Managed Care organizations, they replace Medicare +Choice plans).
MA-PD - Medicare Advantage Prescription Drug plan
Medigap - A supplemental insurance policy provided by a private insurance company designed to provide coverage for medical care not covered by Medicare (some policies have a limited drug benefit).
MMA - Medicare Modernization and Prescription Drug Act
MSA - Medical Savings Accounts
MSP - Medicare Savings Program (these assist with paying for Medicare Part A and/or B costs).
|OTC - Over-the-Counter drugs |
OSH - Oregon State Hospital
PA - Prior Authorization
PACE - Program for the All-inclusive Care of the Elderly (this is an acute LTC provider that is also fully capitated).
Partial Dual Eligible - Medicare beneficiaries (QMB, SLMB, QI 1) with Medicare premiums and/or deductibles paid for by Medicaid, however, there is no actual Medicaid coverage provided.
PBM - Pharmacy Benefits Manager
PDL - Preferred Drug List (also known as a formulary)
PDP - Prescription Drug Plan
QI-1 - Qualified Individual (Medicare Savings Program)
QMB - Qualified Medicare Beneficiary (Medicare Savings Program).
Quantity Limit - A limit placed on the quantity of a medication covered by an insurance company.
|Self-Administer - Medicare considers a drug to be self-administered when patients are administering the drug more than 50% of the time. |
SLMB - Specified Low-Income Medicare Beneficiary (Medicare Savings Program).
SNP - Special Needs Plan (an FCHP that serves primarily institutionalized clients and those with Medicaid).
SPA - State Plan Amendment
SPAP - State Pharmaceutical Assistance Program (Oregon does not have an SPAP).
SPD - Seniors and People with Disabilities
SSA - Social Security Administration
Step Therapy - Trial of an alternative drug before coverage is provided for the originally prescribed drug.
TrOOP - True Out-of-Pocket costs