MedicareEnrollmentChecklist

Welcome to the Medicare Support Center at CVS web and mobile experience. The Medicare Support Center at CVS is an educational and enrollment program owned and operated by CareFree Insurance Services, Inc. (referred to as “CareFree”, “we”, “our” or “us”) for use by Medicare eligible persons (referred to as “you” or “your”) who need assistance with finding a Medicare plan or health insurance that meets your needs and for licensed insurance agents assisting Medicare eligible persons (also referred to as “you” and “your”). These Terms of Use (the “Terms”) apply to those websites and software applications, including mobile applications, and their content (the “Application(s)”) that we license or operate and that contain a link to these Terms.

By clicking “create account”, “Add Medications”, “Enroll” or similar button on the Applications to submit your information to us or a third-party Medicare plan or insurance company, or by otherwise using our Applications you are agreeing to these Terms. Please read them carefully. If you do not agree to these Terms, please exit the Applications.

NO WARRANTIES

THE APPLICATIONS AND ALL MATERIALS AND CONTENT AVAILABLE THROUGH THE APPLICATIONS ARE PROVIDED “AS IS” AND ON AN “AS AVAILABLE” BASIS, WITHOUT WARRANTY OR CONDITION OF ANY KIND, EITHER EXPRESS OR IMPLIED. TO THE FULLEST EXTENT PERMITTED BY LAW, CAREFREE DISCLAIMS ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, RELATING TO THE APPLICATIONS AND ALL SERVICES, MATERIALS AND CONTENT AVAILABLE THROUGH THE APPPLICATIONS, INCLUDING: (A) ANY IMPLIED WARRANTY OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, QUIET ENJOYMENT, OR NON-INFRINGEMENT; AND (B) ANY WARRANTY ARISING OUT OF COURSE OF DEALING, USAGE, OR TRADE. TO THE FULLEST EXTENT PERMITTED BY LAW, WE DO NOT WARRANT THAT THE APPLICATIONS OR ANY PORTION OF THE APPLICATIONS, SERVICES OR ANY MATERIALS OR CONTENT OFFERED THROUGH THE APPPLICATIONS, WILL BE UNINTERRUPTED, SECURE, OR FREE OF ERRORS, VIRUSES, OR OTHER HARMFUL COMPONENTS, AND DO NOT WARRANT THAT ANY OF THOSE ISSUES WILL BE CORRECTED. NO ADVICE OR INFORMATION, WHETHER ORAL OR WRITTEN, OBTAINED BY YOU FROM THE APPPLICATIONS OR SERVICES OR ANY MATERIALS OR CONTENT AVAILABLE THROUGH THE APPPLICATIONS WILL CREATE ANY WARRANTY REGARDING THE APPLICATIONS THAT IS NOT EXPRESSLY STATED IN THESE TERMS. TO THE FULLEST EXTENT PERMITTED BY LAW, YOU ASSUME ALL RISK FOR ANY DAMAGE THAT MAY RESULT FROM YOUR USE OF OR ACCESS TO THE APPLICATIONS, YOUR DEALING WITH ANY OTHER USER, AND ANY MATERIALS OR CONTENT AVAILABLE THROUGH THE APPLICATIONS. YOU UNDERSTAND AND AGREE THAT YOU USE THE APPLICATIONS, AND USE, ACCESS, DOWNLOAD, OR OTHERWISE OBTAIN MATERIALS OR CONTENT THROUGH THE APPLICATIONS AND ANY ASSOCIATED SITES OR SERVICES, AT YOUR OWN DISCRETION AND RISK, AND, TO THE FULLEST EXTENT PERMITTED BY LAW, THAT YOU ARE SOLELY RESPONSIBLE FOR ANY DAMAGE TO YOUR PROPERTY (INCLUDING YOUR COMPUTER SYSTEM OR MOBILE DEVICE USED IN CONNECTION WITH THE APPLICATIONS), OR THE LOSS OF DATA THAT RESULTS FROM THE USE OF THE APPLICATIONS OR THE DOWNLOAD OR USE OF THAT MATERIAL OR CONTENT.

LIMITATION OF LIABILITY

IN NO EVENT WILL CAREFREE BE LIABLE TO ANY PARTY FOR ANY DIRECT, INDIRECT, SPECIAL OR OTHER CONSEQUENTIAL DAMAGES ARISING OUT OF ANY USE OF THE APPLICATIONS, OR ANY OTHER HYPER-LINKED WEBSITE OR SOFTWARE APPLICATION (INCLUDING MOBILE APPLICATIONS), INCLUDING, WITHOUT LIMITATION, ANY LOST PROFITS, BUSINESS INTERRUPTION, LOSS OF PROGRAMS OR DATA ON YOUR EQUIPMENT, OR OTHERWISE, EVEN IF WE ARE EXPRESSLY ADVISED OF THE POSSIBILITY OR LIKELIHOOD OF SUCH DAMAGES.

Ownership of the Applications

The Applications (including any content made available through the Applications) are the property of CareFree (or its licensors) and are protected by applicable intellectual property laws. The Applications are licensed, not sold, to you. You may utilize the Applications only as permitted by these Terms. You may not, and will not permit any other party to: (1) modify, adapt, alter, translate or create derivative works of the Applications; (2) use or merge the Applications, or any component or element thereof, with other software, databases or services not provided by CareFree; (3) sublicense, distribute, sell or otherwise transfer the Applications to any third party; (4) use the Applications as a service bureau, or lease, rent or loan the Applications to any third party; (5) reverse engineer, decompile, disassemble or otherwise attempt to derive the source code or structure of the Applications; (6) interfere in any manner with the operation of the Applications; (7) circumvent, or attempt to circumvent, any electronic protection measures in place to regulate or control access to the Applications; (8) create a database by systematically downloading and storing the Applications; (9) use any robot, spider, site search/retrieval application or other manual or automatic device to retrieve, index, “scrape” “data mine” or in any way gather the Applications or reproduce or circumvent the navigational structure or presentation of the Applications without our express prior written consent; or (10) use the Applications for any commercial purposes. You agree not to develop, distribute or sell any software or other functionality capable of launching, being launched from or otherwise integrated with the Applications. You may not remove, alter or obscure any copyright notice or any other proprietary notice that appears on or in the Applications.

We may freely use feedback you provide, including in future modifications of the Applications, other products or services, advertising or marketing materials. You grant CareFree a perpetual, worldwide, fully transferable, sub-licensable, non-revocable, fully paid-up, royalty free license to use the feedback you provide to us in any way.

Third-Party Resources

The Applications may contain links to, or otherwise make available, third-party sites, Medicare plans, other insurance products, services, products, information, content, materials, merchandise, functionality and/or other resources (“Third-Party Resources”). These Third-Party Resources and links and access to them are provided for your convenience and reference only. We do not control such Third-Party Resources and, therefore, we are not responsible for such Third-Party Resources, or any content posted on or made available by such Third-Party Resources. Be aware that we do not control, and we make no guarantees about, and disclaims any express or implied representations or warranties about such Third-Party Resources, including without limitation the security of any materials, or the accuracy, relevance, timeliness, completeness, or appropriateness for a particular purpose of the information or the resources contained on or made available by such Third-Party Resources or any other Internet sites. We reserve the right to terminate such links or such access at any time. The fact that we offer such links or access should not be construed in any way as an endorsement, authorization, or sponsorship of such Third-Party Resources, or any content made available thereby. Because some Third-Party Resources employ automated search results or otherwise link you to Third-Party Resources containing information that may be deemed inappropriate or offensive, we cannot be held responsible for the accuracy, copyright compliance, legality, or decency of material contained in or made available by Third-Party Resources, and you hereby irrevocably waive any claim against us with respect to such Third-Party Resources. Your use of any Third-Party Resources is subject to the third-party’s terms, conditions and policies applicable to such products, services or materials (such as Terms of Service or Privacy Policies of the providers of such products, services or materials). We are not responsible for the privacy and security of any information you share with that third-party, including your credit card or payment information. When you elect to receive these services from a third-party, you agree to hold that third- party responsible for any unauthorized use or disclosure of your personal information.

Plan Enrollment Applications

We may provide tools through the Applications that enable you to enroll in and export information to Third-Party Resources. By using one of these tools, you agree that we may transfer that information to the applicable third-party. Third-Party Resources are not under our control, and we are not responsible for any Third-Party Resource’s use of your exported information. The Applications may also contain links to third-party websites. Linked websites are not under our control, and you agree we are not responsible for their content.

If you decide to enroll in a third-party plan or insurance using the Applications, at the end of the process you may be asked to provide an electronic signature which will be applied to your enrollment and to other required forms electronically, as applicable. Your electronic signature will be as legally binding and enforceable as if you had signed on paper with a pen.

If you decline the electronic signature process, we may decline to process your enrollment electronically if a signature is required. If required by applicable law, you may still apply with a paper enrollment form, but it could take longer to process it.

The hardware and software descriptions below that are what you will need to use Applications for enrollment in Medicare plans or other health insurance and to receive consumer disclosures, written communications, plan documents, enrollment instructions and confirmations electronically (“Electronic Records”).

Hardware/ Operating Systems: Any PC or MAC with standard Operating Systems
Browsers: Medicare Support Center at CVS is supported in full in
- Google Chrome
- Mozilla Firefox
- Safari (Version 14 or later)
- Microsoft edge
For the best possible experience, your web browser should be fully up to date.
PDF Reader: Adobe Reader version 8 or higher
Internet Bandwidth: High-speed internet connection recommended
A valid email address

The computer hardware and software used to access Applications on the internet is all you will need to access the documents provided to you in electronic form. To retain copies of these documents, you may: 1) print them from the Applications, or 2) save an electronic copy onto a computer. By using the Applications to enroll in a Medicare plan or insurance you agree to submit enrollment information to the selected plan or insurance company through the Application and agree to accept delivery by electronic means all applicable documents. This means you are agreeing that CareFree and the applicable Medicare Plan or insurance company may deliver documents or information about your health care coverage to you at your email address. You also agree that the documents or information about your health care coverage that we deliver to you electronically will satisfy any legal communication requirements, including that those communications be in writing, unless otherwise required by law. If you wish to revoke this consent, you may do so by calling the toll-free number that appears on the Medicare Support Center at CVS website, but such revocation will not affect any actions that a Medicare plan or insurance company or CareFree may have already taken in reliance on your initial consent.

You are responsible for keeping your contact information up to date to ensure timely receipt of instructions and confirmations. You can update your contact information on your profile page at any time or by calling the toll-free number that appears on the Medicare Support Center at CVS website.

Not a Substitute for Professional Health Care Advice

The health information contained in these Applications is general in nature and is not a substitute for professional health care. It is not meant to replace the advice of health care professionals. If you have specific health care needs, or for complete health information, please see a doctor or other health care provider.

Privacy

The privacy policy governing your access to and use of the Applications can be reviewed at our Web Privacy Statement which is hereby incorporated into these Terms. At the top of each page on this website there are links to our Privacy Policy under “Terms and policies”.

Note that, depending on the benefits you select when using the Applications, you may be protected by federal and other law applicable to personally identifiable information about you such as health information protected by the Health Insurance Portability and Accountability Act (“HIPAA”).

Changes to the Applications or Terms

These Terms may be changed or updated without notice. You can determine when these Terms were last revised by referring to the “Version date” at the bottom of these Terms. We may also make improvements and/or changes in the Applications at any time without notice. Your continued use of the Applications after any changes to the Terms indicates your agreement to the changes.

Governing Law

Pennsylvania state law governs these Terms without regard to its conflicts of laws provisions. To resolve any legal dispute arising from these Terms, you agree that the exclusive jurisdiction for such a dispute shall be the state courts in Montgomery County, Pennsylvania, U.S.A. or federal court for the district. CareFree’s failure to insist upon or enforce strict performance of any provision of these Terms shall not be construed as a waiver of any provision or right. Neither the course of conduct between you and CareFree nor trade practices shall act to modify any provision of these Terms. We may assign our rights and duties hereunder to any third-party at any time without notice to you.

Indemnity

You agree to indemnify and hold harmless CareFree, and its officers, directors, employees, affiliates, agents and other third parties permitted to receive your information from any and all claims, liability and expenses, including reasonable attorneys’ fees and costs, arising out of your use of the Applications or your breach of these Terms (collectively, “Claims”). CareFree respectively reserves the right, in its sole discretion and at its own expense, to assume the exclusive defense and control of any Claims. You agree to reasonably cooperate as requested by us in the defense of any Claims.

Entire Agreement

These Terms are the entire agreement between you and CareFree and replace all prior understandings, communications and agreements, oral or written, regarding its subject matter. If any court of law, having the jurisdiction, rules that any part of these Terms are invalid that section will be removed without affecting the remainder of the Terms. The remaining terms will be valid and enforceable.

Version date: August 6, 2021

Collecting and using personal information

Welcome to Medicare Support Center at CVS websites and mobile applications. The Medicare Support Center at CVS is an educational and enrollment program owned and operated by CareFree Insurance Services, Inc. (referred to as "CareFree", "we" or "us"). We appreciate your interest in us. When you visit and navigate our sites and when you communicate with us via our sites, we will not collect personal information about you unless you provide us that information voluntarily. Any non-public personal information that you may provide via our sites will be used solely for the purpose stated on the page where it is collected. (In some cases, and in all cases where required by law or regulation, you will be able to update the information that you provide to us either by sending us an e-mail or, where you have established personal profiles with us, by updating your profile online. Please refer to the specific pages where data is collected for more information.) CareFree will not sell, license, transmit or disclose this information outside of CareFree and its affiliated companies unless (a) expressly authorized by you, (b) necessary to enable CareFree contractors or agents to perform certain functions for us, or (c) required or permitted by law. In all cases, we will disclose the information consistent with applicable laws and regulations and we will require the recipient to protect the information and use it only for the purpose it was provided.

By “personal information,” we mean data that is unique to an individual, such as a name, address, Social Security number, e-mail address, or telephone number. From time to time, we may request personal information from you at our sites in order to deliver requested materials to you, respond to your questions, or deliver a product or service.

Your e-mail

We welcome you to contact us through e-mail or calling. Your e-mail will be sent to our licensed agents and those employees most capable of addressing your questions and providing a response.

Please note that your e-mail, like most, if not all, non-encrypted Internet e-mail communications, may be accessed and viewed by other Internet users, without your knowledge and permission, while in transit to us. For that reason, to protect your privacy, please do not use e-mail to communicate information to us that you consider confidential. If you wish, you may contact us instead via non-cellular telephone at the numbers provided at various locations on our site.

Other information; “cookies” and “tags”

You should also be aware that when you visit our websites, we collect certain information that does not identify you personally, but provides us with “usage data,” such as the number of visitors we receive or what pages are visited most often. This data helps us to analyze and improve the usefulness of the information we provide at these websites.

Like most commercial website owners, we may use what is known as “cookie” technology. A “cookie” is an element of data that a website can send to your browser when you link to that website. It is not a computer program and has no ability to read data residing on your computer or instruct it to perform any step or function. By assigning a unique data element to each visitor, the website is able to recognize repeat users, track usage patterns and better serve you when you return to that site. The cookie does not extract other personal information about you, such as your name or address.

We may also use what is known as “client-side page tagging”, which uses code on each page to write certain information about the page and the visitor to a log when a page is rendered by. Like most commercial website owners, we may use what is known as “cookie” technology. A “cookie” is an element of data that a website can send to your browser when you link to that website. It is not a computer program and has no ability to read data residing on your computer or instruct it to perform any step or function. By assigning a unique data element to each visitor, the website is able to recognize repeat users, track usage patterns and better serve you when you return to that site. The cookie does not extract other personal information about you, such as your name or address.

Version date: October 12, 2021

Annual Enrollment Period (AEP): It's a set time when current Medicare members can drop or change their Medicare health or drug plan. Or switch to Original Medicare. A person eligible for Medicare can also join a Medicare plan at this time if they missed their first chance for enrollment. The Annual Enrollment Period is from October 15 until December 7.
Appeal: Is the action a member takes when disagreeing with a coverage or payment decision made by Medicare, their Medicare health plan, or their Medicare Prescription Drug Plan.
Beneficiary: A person entitled to health services under a federal Medicare health insurance plan and/or has been determined to be eligible for Medicaid.
Brand-name drug: A prescription drug that is made and sold by the company that originally researched and developed the drug. A brand-name drug has the same active ingredients and formula as its generic version. Generally, other companies cannot make generic versions of brand-name drugs until after the patent on the brand-name drug expires.
Case management programs: Programs with case managers who help coordinate care for people with complex care needs.
Catastrophic coverage stage: This is the drug coverage stage that happens after a member gets out of the coverage gap (donut hole). With catastrophic coverage, a member pays a reduced amount for covered drugs for the rest of the year.
Centers for Medicare and Medicaid Services (CMS): A federal agency under the U.S. Department of Health and Human Services (HHS). CMS is in charge of several programs including Medicare, Medicaid, the Children’s Healthcare Program (CHIP), and the state and federal insurance marketplaces.
Coinsurance: Amount a member may have to pay for their share of services. Coinsurance is usually a percentage (for example, 20%).
Complaint: The formal name for “making a complaint” is “filing a grievance.” Members can use the complaint process for certain types of problems they may have with their plan’s service. These include issues with quality of care, wait times, and customer service. Also see “Grievance.”
Copay / Copayment: Amount members may have to pay for their share of services. Copays are usually a set amount (for example, $10 for a prescription drug or $20 for a doctor’s visit).
Cost sharing: What members pay for care. Examples of cost-sharing can include a deductible, copayment, or coinsurance.
Coverage determination: The first decision a member's Medicare drug plan (not the pharmacy) makes about their benefits. This can be a decision about if a member's drug is covered, if a member met their plan’s requirements to cover the drug, or how much a member pays for the drug. A member also receives a coverage determination decision if they ask their plan to make an exception to its rules to cover their drug.
Coverage gap: Also called the “donut hole.” The coverage gap is the period that begins after a member and their drug plan together spend a certain amount for covered drugs. When in the coverage gap, members pay no more than 25% of the cost for their plan’s covered prescription drugs. The coverage gap ends when a member spends enough to qualify for catastrophic coverage.
Deductible: This is the amount some plans require members pay for covered services before their plan starts paying.
Disenroll: This means ending membership in a health plan. Disenrollment may be voluntary (member's choice) or involuntary (not member's choice).
Donut hole: Also called the “coverage gap.” The donut hole is the period that begins after a member and their drug plan together spend a certain amount for covered drugs. When in the donut hole, members pay no more than 25% of the cost for their plan’s covered prescription drugs. The donut hole ends when a member spends enough to qualify for catastrophic coverage.
Drug tier: This is a group of drugs on a formulary. Each group or tier requires a different level of payment. Members may see the groups listed as generic drugs, brand-name drugs, or preferred brand-name drugs. Higher tiers usually have higher cost sharing. For example, a drug on Tier 2 generally costs more than a drug on Tier 1.
Enrollee: A member of a Medicare health plan.
Evidence of Coverage (EOC): The EOC gives a plan member detailed information on the plan’s coverage, costs, and member rights and responsibilities.
Exception: A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan's decision to cover a drug that's not on its drug list or to waive a coverage rule. A tiering exception is a drug plan's decision to charge a lower amount for a drug that's on its non-preferred drug tier. A member or their prescriber must request an exception. And the member's doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.
Extra Help: Program that helps people with limited incomes and resources pay their Medicare prescription drug plan costs, such as premiums, deductibles and coinsurance. The Extra Help program is run by the Social Security Administration.
Formulary: This is a list of prescription drugs covered by a plan. It’s also called a drug list.
Generic drug: A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand-name drug. Generally, a “generic” drug works the same as a brand-name drug. And usually costs less.
Grievance: A complaint about the way a member's Medicare health plan or drug plan is giving care. For example, a member may file a grievance if they have a problem calling the plan. Or if they're unhappy with the way a staff person at the plan has behaved towards them.
Group health plan: Also called group coverage. In general, a health plan offered to an employer or employee organization that provides health coverage to employees and their families.
Health Maintenance Organization (HMO): A type of Medicare Advantage Plan (Part C) available in some areas of the country. In most HMOs, the member can only go to doctors, specialists, or hospitals on the plan's list except in an emergency. Most HMOs also require members to get a referral from their primary care physician.
Initial coverage limit: This is a set amount of drug costs. It includes what the member pays, plus what their plan pays. When the initial coverage limit is reached, a member enters the coverage gap (donut hole). And the terms of the member's benefit change.
Initial coverage stage: This is the stage after a member meets their deductible (if it applies) and before a member's total drug costs reaches the initial coverage limit. During the initial coverage stage, the plan pays some of the costs for covered prescription drugs. And the member pays a copayment or coinsurance. Total drug costs include what the member and their plan has paid for member's covered drugs.
Initial Enrollment Period (IEP): Is the 7-month window a person has to sign up for Part A and/or Part B when first eligible for Medicare. It begins 3 months before a beneficiary turns 65, includes the month the beneficiary turns 65, and ends 3 months after the month the beneficiary turns 65.
In network: Refers to providers or health care facilities that are part of a health plan's network of providers. And have negotiated a discount with the health plan.
Late enrollment penalty (Part D): The cost of the Part D late enrollment penalty is based on how long a Medicare beneficiary was without creditable prescription drug coverage.
Low-income subsidy (LIS) See "Extra Help.”: MA Plan Type of Medicare Advantage health plan offered by a private insurance company that contracts with Medicare. Medicare Advantage Plans provide all of a member's Part A and Part B benefits, excluding hospice. This type of Medicare Advantage Plan doesn't cover prescription drugs.
MAPD Plan: Type of Medicare Advantage health plan offered by a private insurance company that contracts with Medicare. Medicare Advantage Plans provide all of a member's Part A and Part B benefits, excluding hospice. This type of Medicare Advantage Plan includes Medicare prescription drug coverage.
Maximum out-of-pocket amount: The most a member will pay in a year for certain health services. The plan's Evidence of Coverage provides detailed information, including the maximum amount a member will pay.
Medicaid (Medical Assistance): A joint federal and state program that helps with medical costs for specific individuals with limited income and resources. Individuals include low-income adults, children, elderly adults, and people with disabilities. Medicaid programs vary from state to state. Most health care costs are covered if the person qualifies for both Medicare and Medicaid.
Medicare: Medicare is the federal health insurance program for: 1) People who are 65 or older; 2) Certain younger people with disabilities; 3) People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Medicare Part D: This refers to prescription drug coverage. Medicare Part D is obtained through a Medicare Advantage plan offering prescription drug coverage. Or it can be obtained through a separate standalone prescription drug plan.
Medigap or Medicare Supplement: Both names refer to Medicare Supplement insurance. Private insurance companies sell it to fill “gaps” in Original Medicare. Medigap (Medicare Supplement) policies only work with Original Medicare. A Medicare beneficiary cannot have a Medicare Advantage Plan and a Medigap policy.
Member: A person with Medicare who is eligible and enrolled in either Original Medicare or a Medicare Advantage plan. Enrollment is confirmed by the Centers for Medicare & Medicaid Services.
Network: Is all the doctors, clinics, hospitals and/or pharmacies that have a contract with a health plan. Members pay the least amount for health care when obtaining services in network.
Network pharmacy: A pharmacy that has a contract with a health plan. Generally, the health plan will only cover member prescriptions when filled at a network pharmacy.
Network provider: A provider that has a contract with a health plan. The plan pays a network provider based on the contract. Network providers are also called plan providers.
Optional supplemental benefits: These are benefits that Medicare doesn’t cover. Medicare beneficiaries can purchase them for an additional premium.
Organization determination (coverage decision): Any decision made by a Medicare health plan about whether they cover items or services. Or how much a member must pay for covered items or services.
Out-of-network pharmacy: A pharmacy that doesn’t have a contract with a health plan. Most plans will not cover drugs received from out-of-network pharmacies, unless certain conditions apply.
Out-of-network provider or out-of-network facility: A provider or facility that does not have an agreement with a health care plan for reimbursement at a negotiated rate.
Point-of-Service (POS): A type of health plan that is a cross between HMO and PPO plans. Like an HMO, a member selects an in-network doctor to be their primary care provider. But like a PPO, members may go outside of the provider network for health care services. When going out of the network, members pay most of the cost, unless their primary care provider made a referral to the out-of-network provider. Then the health plan pays the cost.
Preferred pharmacy: A pharmacy that contracts with a Part D plan. And provides members covered prescription drugs at negotiated prices. Cost sharing is often lower at preferred pharmacies. Plans must let members know if they offer standard and/or preferred pharmacy network benefits.
Preferred Provider Organization (PPO): A type of Medicare Advantage Plan (Part C) available in some areas of the country. Members pay less if they use doctors, hospitals, and other health care providers that belong to the plan's network. Members can use doctors, hospitals, and providers outside of the network for an additional cost.
Premium: This is the amount a member pays for coverage. If a member obtains coverage from an employer or group health plan, the costs might be shared between the member and the employer.
Primary Care Physician (PCP) or Primary Care Doctor: A PCP is a doctor who is part of a health plan's network. A member's PCP is their main contact for care. The PCP also gives referrals for other care. They coordinate the care members get from specialists or other care facilities. Some health plans require members choose a PCP.
Prior authorization: Some services or prescription drugs require a member's doctor and their plan to approve them before a member can obtain care or fill a prescription. The approval tells a member if the plan covers the requested service or prescription. Members must check with their plan to see which drugs or services need prior authorization. Prior authorization is also called precertification, certification, and authorization. (In Texas, this approval is known as pre-service utilization review and is not verification as defined by Texas law.)
Provider: The doctor, hospital, pharmacy, or other licensed professional or facility that provides medical services.
Quantity Limits (QL): With most drugs, only a certain amount can be dispensed at one time for safety, quality, or usage reasons.
Referral: A written order from a member's primary care doctor to see a specialist or get certain medical services. Many HMOs require a referral before a patient can get medical care from anyone except their primary care doctor. If a referral isn't obtained first, the plan may not pay for the services.
Special Enrollment Period (SEP): Also called a Special Election Period. If you have a Medicare plan, it’s a time when you can change your benefits because something in your life changes. Examples are moving out of a plan’s service area, or being able to get Medicaid.
Special Needs Plan (SNP): A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people. Groups include those who have both Medicare and Medicaid, those living in a nursing home, or those with certain chronic conditions.