Annual Election Period: The Annual Election Period is between November 15 - December 31 and this is when you can switch PDP providers. This is the only time you can choose a new plan. There are exceptions to this rule that will allow you to change your plan outside of the Annual Election Period including if you lose your extra help or if you move out of the service area.  Call WellCare for full details.

Appeal: An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for prescription drugs or payment for prescription drugs you already received. For example, you may ask for an appeal if our Plan doesn't pay for a drug you think you should be able to receive.

Brand-Name Drug: A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand-name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand-name drug has expired.

Catastrophic Coverage: The phase in the Part D Drug Benefit where you pay a low co-payment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,550 in covered drugs during the covered year.

Coinsurance: This is an amount you pay for each prescription at the pharmacy — it's a percentage of what the drug costs.

 

Co-pay: This is also an amount you have to pay for each prescription at the pharmacy — it's usually a flat dollar amount.

Cost-sharing: Cost-sharing refers to amounts that a member has to pay when drugs are received. It includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before drugs are covered; (2) any fixed "co-payment" amounts that a plan may require be paid when specific drugs are received; or (3) any "coinsurance" amount that must be paid as a percentage of the total amount paid for a drug.

Coverage Determination: A decision from your Medicare drug plan about whether a drug prescribed for you is covered by the Plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage if you disagree.

 

Deductible: The amount you must pay for the drugs you receive before our Plan begins to pay its share of your covered drugs.

Exception: A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the Plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Formulary: A list of covered drugs provided by the Plan.

 

Generic Drugs: 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, generic drugs cost less than brand-name drugs. For more on generic drugs, click here.

Grievance: A type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Initial Enrollment Period: When you're turning 65 (or first become eligible for Medicare), this is the period during which you may first enroll in a PDP. The initial enrollment period begins three months before you are eligible for Medicare and ends three months after the month that you became eligible. For most people, that means you can start enrolling in a PDP three months before your 65th birthday (when you become eligible for Medicare Parts A and B). Then, after your birthday month ends, you have another three months to enroll.

 

Initial Coverage Limit and the gap or donut hole: This is the limit after you have met your deductible and before your total drug expenses have reached $2,830, including amounts you've paid and what our Plan has paid on your behalf. At this point, your coverage changes and you enter the gap or donut hole. While you're in the gap, you must pay for your prescriptions yourself UNTIL you've spent $4,550 of your own money. Then your coverage changes again, and you pay 5% of your remaining costs. This is a common feature of many PDP plans. 

 

Late Enrollment Penalty: An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that expects to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. 

 

Monthly Premium: This is the amount you pay for coverage each month. It's just like a monthly bill.

Network Pharmacy: A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them "network pharmacies" because they contract with our Plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

 

Non-covered Drugs: These drugs are not covered by any WellCare plan.

 

Non-preferred Brand Drugs: These drugs are not on the WellCare preferred list. You can continue to use these drugs with any WellCare plan, but you may pay more, as is detailed in the plan chart.

Out-of-Network Pharmacy: A pharmacy that doesn't have a contract with our Plan to coordinate or provide covered drugs to members of our Plan. As explained in the Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our Plan unless certain conditions apply.

 

Pharmacy Network: This is the group of pharmacies who have contracted with the PDP to save you money on prescriptions. WellCare has over 64,000 pharmacies in our network.

 

Preferred Brand Drugs: Among brand drugs, these are the ones WellCare prefers, so they are less costly. These brand drugs generally have lower co-pays than non-preferred brand drugs.

 

Prior Authorization: Approval in advance to get certain drugs that may or may not be on our formulary. Some drugs are covered only if your doctor or other network provider gets prior authorization from us. Covered drugs that need prior authorization are marked in the Formulary.

 

Quantity Limits: A management tool that is designed to limit the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug we cover per prescription or for a defined period of time. 

 

Step Therapy: A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.