KEY TERMS  

Antidepressants:  Drugs used to prevent depression.

Antipsychotics:  Drugs that counteract or alleviate the symptoms of a psychiatric disorder such as schizophrenia.

Anticonvulsants:  Drugs for preventing or reducing the incidence of seizures.

Antiretrovirals:  Drugs used in the treatment of HIV and AIDS.

Antineoplastics:  Drugs used to prevent or slow the growth of cancers. 

Auto-Assignment:  For individuals who receive both Medicare and Medicaid benefits, the Centers for Medicare and Medicaid will randomly assign the person to a prescription drug plan effective January 1, 2006.

Co-Pay:  A fee that the individual pays each time they purchase a drug.  The co-pays for individuals who are dually eligible for Medicaid and Medicare are established in the law.  

Cost Tiers:  A system that drug plans use to price medications. Generic drugs are generally on the first and least expensive tier, followed by brand-name drugs, and then specialty drugs, with each subsequent tier requiring higher out-of-pocket costs. 

Centers for Medicare and Medicaid Services (CMS):  The federal agency with responsibility for implementing the Medicare Modernization Act, issuing regulations, approving the drug plans, providing technical assistance to the public, etc.

Deductible:  An amount the individual must pay before Medicare will begin paying for drugs. Dual eligibles are not required to pay deductibles.

Drug Formulary:  A list of prescription medications that a drug plan will pay for.  When medications are not listed on a drug plan’s formulary, then the drug plan will not pay for them.

Dual eligible:  An individual who receives both Medicare and Medicaid benefits.

Excluded Drug:  There are certain drugs, or uses of drugs, that the law excluded from the definition of a Medicare Part D drug.  This means that they cannot be provided as part of basic coverage.

Exception:  The Prescription Drug Plans must have an exceptions process for enrollees to request that their plan cover a medically necessary drug not on its formulary.

Extra Help:  Subsidies that are available to low income individuals to help pay the costs of the prescription drug coverage.  Individuals who are dually eligible for Medicare and Medicaid will automatically receive the extra help; others must apply for the assistance.

Immunosuppressants:  Drugs used to prevent the rejection of transplanted organs and may be used for the treatment of multiple sclerosis, lupus and some types of rheumatoid arthritis.

Legally Authorized Representative:  An individual who can select and enroll in a Medicare prescription drug plan on behalf of a person with a cognitive disability. CMS has stated that each state will decide who is considered a legally authorized representative for this purpose.  Families and caregivers are urged to contact their State Medicaid agencies or check www.ucp.org or www.thearc.org for updates on this issue.

Long Term Care Facility:  Long term care facilities include nursing facilities, Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) and other medical institutions that receive Medicaid payments for institutionalized individuals.  Specifically not included are individuals who are supported by Home and Community Based Waivers and other types of residential settings such as assisted living homes and other group homes that are regulated by the state.

Medicare Modernization Act (MMA) of 2003:  The federal law that created the Medicare drug benefit and also resulted in all of the changes for dual eligibles that are discussed in this document.

Off-label use:  When a drug is prescribed for a reason other than the FDA approved use.  

Part D:  This section of the MMA establishes the new Medicare prescription drug coverage.  

Pharmacy Network:  The list of pharmacies that are contracting with a prescription drug plan (PDP).

Premium:  Monthly fees that a plan charges for the prescription drug coverage.

Prescription drug plan (PDP):  A company to which every dual eligible will be automatically assigned.  Each PDP will have its own formulary, pharmacy network and its own procedures.

Prior Authorization:  A requirement by the PDP that a doctor must get approval from the plan before prescribing selected medications.

Step-Therapy: A requirement by the PDP that a person must try one medication before the doctor may prescribe another, more expensive one.

Transition Plan:  The transition plan describes how each PDP will handle the situation where an individual who is stabilized on a drug regime enrolls in a plan that does not include the person’s medication.