Annual enrollment period (AEP)
Sometimes called the annual election period. AEP runs from October 15 through December 7 each year and you make changes to your prescription drug coverage during this time.
Annual Notice of Changes (ANOC)
This is a document that we will send to you each year in September. It outlines what will be changing about the plan for the upcoming year.
An appeal is something you do if you disagree with our decision to deny a request for coverage of prescription drugs or payment for drugs you already received. For example, you may ask for an appeal if we don’t pay for a drug you think you should be able to receive. Learn more about appeals and the process for making an appeal. You can refer to chapter 7 in your Evidence of Coverage for additional information.
Catastrophic coverage stage
If you spend $6,350 out-of-pocket in 2020, you will enter the catastrophic coverage stage. This means you pay only a small coinsurance amount or copay for covered drugs for the rest of the year.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare and Medicaid programs. CMS makes sure beneficiaries like you get access to high quality health care.
Coinsurance is a type of cost sharing and is the percent you pay for a prescription drug. For example, if your coinsurance is 10% and the cost of the drug is $10, you will pay $1. With some plans, you don’t pay coinsurance until you have first paid a deductible. You can find out if your plan option has coinsurance amounts by referring to the Summary of Benefits.
Copayment or copay
Copayment is a type of cost sharing and is a fixed dollar amount you pay for prescription drugs. For example, you may pay a $5 copay for a prescription drug. You can find out if your plan option has copayments by referring to the Summary of Benefits.
This is the portion of a prescription drug cost that you are responsible for paying. Types of cost sharing include copayments, coinsurance and deductibles.
A fixed dollar amount you pay before you will receive coverage for prescription drugs. For example, if you have a $435 deductible for your prescription drug plan, you must spend $435 on prescription drugs before the plan will begin paying. Generally, deductibles are annual.
Evidence of Coverage (EOC)
This document explains your prescription drug coverage, what your provider must do, your rights and what is required of you as a member of the plan. The EOC is updated annually in September and is made available online under the “Plan documents” tab.
Explanation of Benefits (EOB)
This is a statement that you will receive by mail every month that you use your prescription drug benefits. It provides information about the prescription drug services you have received. An EOB is not a bill.
Formulary (drug list)
More commonly known as the drug list, the formulary is a list of drugs that are covered by the plan. Journey Rx formularies feature 5 drug tiers, or levels. Generally, drugs on tier 1 are less expensive than drugs on tier 5.
An expression of dissatisfaction with any aspect of the operations, activities or behavior of a plan or its delegated entity in the provision of health care items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken. A grievance does not include, and is distinct from, a dispute of the appeal of an organization determination or coverage determination or an late enrollment penalty (LEP) determination.
Initial coverage limit
The limit of coverage you receive under the initial coverage stage. In 2020, the initial coverage stage ends if or when you and Journey Rx have spent $4,020 on covered drugs.
Initial enrollment period (IEP)
Sometimes called an initial election period, this is a 7-month period when you are first able to enroll in Medicare. It begins 3 months prior to the month you turn 65, includes the month you turn 65 and ends 3 months after the month you turn 65. For example, if your birthday is May 15, your IEP would be February through August.
Initial coverage stage
A stage that you enter after your deductible has been met and before your total drug expenses reach $4,020 in 2020. This includes amounts that you have paid and amounts that your plan has paid on your behalf.
Medicare prescription drug plan (PDP)
Sometimes called Medicare Part D. These plans can be stand-alone PDPs that you can pair with Original Medicare and/or a Medicare Supplement Insurance (Medigap) plan, or a Medicare Advantage plan that includes prescription drug coverage. Journey Rx is a stand-alone prescription drug plan.
Medicare Supplement Insurance (Medigap) plan
Health insurance policies that usually have standardized benefits and are sold by private insurance companies. Medigap policies can be paired with Original Medicare and/or a prescription drug plan, like Journey Rx. Medigap plans generally allow you the flexibility to go to any doctor or hospital that accepts Medicare.
A pharmacy that allows members to receive their prescription drug benefits. If you use an out-of-network pharmacy, you will pay more for your prescriptions. You can save on your prescriptions by using a network pharmacy that offers preferred cost sharing.
The part of the Medicare program that provides prescription drug coverage.
Part D late enrollment penalty (LEP)
This is an amount that may be added to your Part D monthly premium if you didn’t sign up for a Part D plan when you were first eligible. If you had creditable coverage, for example, coverage from an employer or union group, the penalty will not be applied. The penalty amount varies depending on how long you went without Part D coverage. To learn more about the Part D LEP, visit medicare.gov.
Preferred cost sharing
Some of our network pharmacies offer preferred cost sharing, meaning you pay a lower share of the cost at these pharmacies for your prescription drugs. Not all network pharmacies offer preferred cost sharing.
Use the pharmacy locator tool or contact customer service to locate a pharmacy offering preferred cost sharing near you.
This is the payment that you (or other third party) pays to Journey Rx for your prescription drug plan benefits. Typically, the premium is paid monthly.
You can choose to pay your premium by mail, or you can sign up for electronic funds transfer (EFT) or automatic deductions from your Social Security or Railroad Retirement Board (RRB) distribution checks.
Special enrollment period (SEP)
In some situations, you may be able to make changes to your prescription drug coverage. For instance, if you move, or lose your insurance coverage, you may be entitled to a SEP. Each type of SEP has different rules about when and what types of changes you can make to your coverage. To learn about SEPs, visit medicare.gov.
Standard cost sharing
This is the cost sharing model offered by network pharmacies that don’t offer preferred cost sharing.
A standard pharmacy allows members to fill prescriptions using their plan benefit but does not offer the same low copayments and coinsurance as a preferred network pharmacy.
Summary of Benefits
This is a resource that summarizes your benefits with Journey Rx. It’s written in plain language and can help you compare plans. You can access the Summary of Benefits on the “Plan documents” tab.
Teletypewriter (TTY) is a communication tool used by people who are deaf, hard of hearing or who may have a speech impediment.