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Annual Enrollment Period (AEP)
This is a time each year when you can sign up for, change or leave your Medicare plan. It runs from October 15 through December 7.
Appeal
If we say we won't cover a service or drug, you can ask us to look at the decision again. This is called an appeal.
Brand-name drug
This is a prescription drug made and sold by the company that created it. It has the same active ingredients and formula as its generic version. Usually, other companies can’t make a generic drug until the patent on the brand-name version has expired.
Cancel
To end your plan before it starts. You can do this by choice. But there are times when it is not by choice. The Centers for Medicare & Medicaid Services (CMS) has rules for this.
Case management programs
These are programs that help people with complex care needs. A case manager can help you plan your care and connect you to services.
Catastrophic coverage phase
This is the drug coverage phase that starts after you’ve paid $2,100 out of pocket for your drugs in a year. These drugs must be covered by your Part D prescription drug plan. After that, you will have a $0 copay/coinsurance through the end of the plan year.
Centers for Medicare and Medicaid Services (CMS)
The federal agency that runs the Medicare program. It works with states to run the Medicaid program, too.
Coinsurance
This is a percentage of the cost you pay out of pocket for a covered service or drug. If something costs $100 and your coinsurance is 10%, you pay $10.
Complaint (grievance)
This is a formal process for reporting problems you may have with your plan’s service. These problems may include:
- Issues with quality of care
- Wait times
- Customer service
Copayment (copay)
This is a set amount you pay out of pocket for care or a drug that is covered. For example, you might pay $20 to see a doctor.
Cost sharing
This is what you pay out of pocket for covered care or drugs. It includes your copay, coinsurance and deductible.
Coverage determination
This is the first decision made by your Medicare drug plan about:
- Whether a drug is covered
- If you meet plan rules
- How much you’ll pay
You can ask your plan for an exception if needed.
Chronic Condition Special Needs Plan (C-SNP)
This is a type of Medicare Advantage Special Needs Plan. These plans are for people who need extra support with a qualifying chronic or disabling condition. These are conditions that are approved by the Centers for Medicare & Medicaid Services (CMS).
Deductible
This is the amount you have to pay out of pocket each year before your plan starts to pay for medical care or prescription drugs. Your deductible resets at the beginning of each plan year.
Disenroll
To leave your plan after it has started. You can do this by choice. But there are times when it is not by choice. The Centers for Medicare & Medicaid Services (CMS) has rules for this.
Drug tier
Drugs on your plan’s formulary (drug list) are grouped into levels called tiers. What you pay depends on the drug’s tier. Drugs on lower tiers usually cost less. Drugs on higher tiers usually cost more.
Dual-Eligible Special Needs Plan (D-SNP)
This is a type of Medicare Advantage Special Needs Plan. It is for people who qualify for Medicare and Medicaid. It offers added support and coverage.
Enrollee
A member of our Medicare plan.
Evidence of Coverage (EOC)
This is a document that explains:
- What your plan covers
- What you’ll pay for medical care or prescription drugs
- Your rights and how to get help
Exception
An exception is a special approval. If you get it, you might:
- Be able to get a drug that’s not on your plan’s formulary (drug list) (a formulary exception)
- Pay less for a drug that usually costs more (a tier exception)
You can also ask for an exception if:
- Your plan wants you to try a different drug first (step therapy)
- Your plan limits how much of a drug it will pay for (quantity limit)
Extra Help (Low-income Subsidy, or LIS)
This is a Medicare program that can help you if you have a low income.
This program can help people pay their:
- Medicare Part D premiums
- Deductibles
- Coinsurance
- Other Part D costs
Formulary(drug list)
This is the list of drugs that your plan covers.
Review the drug list for your plan.
Take a look at Aetna Medicare formularies
Generic drug
This drug has the same active ingredient(s) as a brand-name drug. They usually work the same as the brand-name version and usually cost less.
Grievance (complaint)
This is a formal process for reporting certain problems you may have with your plan’s service. These include things like issues with:
- Quality of care
- Wait times
- Customer service
Group health plan (group coverage)
This is a health plan an employer or other group may offer retirees.
Health maintenance organization (HMO)
This is a type of Medicare plan that has a network of providers. With most HMO plans, you can only use providers in the plan’s network, unless it’s an emergency. And you may need a referral from your primary care physician to see a specialist, too.
In network
This is a doctor or other health care provider we have a contract with. We negotiate reduced rates with network providers to help you save money. Network providers won’t bill you for the difference between their standard rate and their contracted rate. All you pay is your coinsurance or copay, along with any deductible.
Initial coverage phase
This is the phase after you have met your deductible (if it applies). During this phase, you pay part of the cost for each covered Part D prescription drug — a copay or coinsurance.
This phase ends when your total out-of-pocket costs for the year reach $2,100 (in 2026).
Initial Enrollment Period (IEP)
This is the first time you become eligible for Medicare.
It lasts 7 months and:
- It starts 3 months before the month you turn 65
- It includes your birthday month
- It ends 3 months after that month
Institutional Special Needs Plan (I-SNP)
This is a type of Medicare Advantage Special Needs Plan. I-SNPs are for people who expect to need 90 or more days of care and who have had, or are expected to need, the level of services provided in:
- A long-term care (LTC) skilled nursing facility (SNF)
- An LTC nursing facility (NF)
- An SNF/NF
- An intermediate care facility for individuals with intellectual disabilities (ICF/IDD)
- An inpatient psychiatric facility
Late enrollment penalty (Part D)
This is an amount added to your Medicare Part D monthly premium if these are both true:
- You’ve passed your Initial Enrollment Period
- You’ve gone without creditable drug coverage for at least 63 days in a row
Credible coverage means drug coverage that’s at least as good as what Medicare Part D offers.
If you get Extra Help, you won’t have to pay this penalty. If you don’t get Extra Help, you’ll pay the penalty for as long as you have a Medicare drug plan.
Long-term supply
You can get a long-term supply of some maintenance drugs. That’s:
- A 90-day supply with a stand-alone Part D plan (PDP)
- A 100-day supply with a Medicare Advantage plan with Part D drug coverage (MAPD)
You can get a long-term supply of your drug at select retail pharmacies. In some states, you can get them by mail, through CVS Caremark® Mail Service Pharmacy. See also "Maintenance drugs."
MA Plan
This is a Medicare Advantage plan (Part C). These plans don’t cover prescription drugs.
MAPD Plan
This is a Medicare Advantage plan (Part C) that also includes Part D prescription drug coverage.
Mail-order pharmacy
This is a pharmacy where you can get a long-term supply of maintenance drugs delivered to you by mail.
Maintenance drugs
A drug you take regularly for a chronic or long-term health issue, like high blood pressure.
Maximum out-of-pocket (MOOP)
This is the most you’ll pay out of pocket in a plan year for covered care. Once you reach this limit, we pay 100% of the cost for covered services.
Your limit does not include:
- Your monthly plan premium
- What you pay for prescription drugs
You can find your MOOP in your plan’s Summary of Benefits or Evidence of Coverage.
Medicaid (Medical Assistance)
A program that provides health coverage to:
- People with low income
- Children
- Elderly adults
- People with disabilities
Medicaid is funded both by states and the federal government. States manage it according to federal rules.
Learn more about the differences between Medicare and Medicaid
Medicaid Advantage Plus
This is a program especially designed for people who have Medicare and full Medicaid. It is also for people who need long-term care services, like personal care, to stay in their homes and communities as long as possible.
Medicare
This is a federal health insurance program for people ages 65 or older. Some people under age 65 may also qualify.
People with Medicare can get their health coverage through:
- Original Medicare
- A Medicare Cost plan
- A Program of All-Inclusive Care for the Elderly (PACE) plan
- A Medicare Advantage plan
Medicare Part D
This is a type of prescription drug coverage. You can get Part D through:
- A Medicare Advantage plan that covers prescription drugs
- Or a stand-alone prescription drug plan
Medicare Supplement Insurance (Medigap or Med Supp)
This insurance helps to pay for out-of-pocket costs that Original Medicare doesn’t cover. You can pair a Medigap plan with Original Medicare. But you can’t pair Medigap with a Medicare Advantage plan.
Member
A person with Medicare who:
- Is eligible for covered services
- Has enrolled in our plan
- Has had their enrollment confirmed by the Centers for Medicare & Medicaid Services (CMS)
Network
A group of health care providers that includes doctors, dentists and hospitals. A health care provider in a network signs a contract with a health plan to provide services. Usually, a network provider provides these services at a special rate. With some health plans, you get more coverage when you get care from network providers.
Network pharmacy
A pharmacy that has a contract with our plan. In most cases, we only cover your prescriptions if you fill them at a network pharmacy.
Network provider
A provider that has a contract with our plan. A health care provider in a network signs a contract with a health plan to provide services. Usually, a network provider provides these services at a special rate. With some health plans, you get more coverage when you get care from network providers.
Optional supplemental benefits
These are benefits you can choose to add to your Medicare Advantage plan at an extra cost. Like added coverage for dental.
Out-of-network pharmacy
This is a pharmacy that doesn’t have a contract with us. Most times, we won’t cover a drug that you get from an out-of-network pharmacy. There are some special cases when we will.
Out-of-network provider
This is a provider that doesn’t have a contract with us.
Point-of-Service (POS)
This is a type of plan with a network of providers. Some POS plans let you use providers outside the network. But you may pay more for your care.
Preferred pharmacy
This is a pharmacy that has a contract with our plan. The out-of-pocket cost for your drug (or cost share) is often lower here. We list network pharmacies in our online directory.
Preferred provider organization (PPO)
This is a type of plan with a network of providers. You can use out-of-network providers, too. But you may pay more for your care.
Premium
This is the amount you pay each month to your plan for medical or drug coverage. You may get coverage from an employer or group health plan. If so, you and the employer may share this cost.
Primary care physician or primary care provider (PCP)
This is your main contact for care. A PCP can give you a referral to see a specialist and coordinate your care. They can also help you monitor and manage any chronic health issues you have, like diabetes or high blood pressure. Some health plans require you to have a PCP.
Prescription drug plan (PDP)
This is a stand-alone Medicare Part D plan that covers prescription drugs. Depending on the plan, it may cover some vaccines, too.
Prior authorization
PA is a coverage rule. This is when your doctor must ask your plan for approval before you get a service or drug. The approval tells you if the plan covers the service or prescription. Check with your plan to see which drugs or services need PA.
PA is also called:
- Precertification
- Certification
- Authorization
- Pre-service utilization review (in Texas)
Provider
This is a doctor, hospital, pharmacy or other licensed professional or facility that provides health care services.
Quantity Limit (QL)
Your plan’s quantity limit is a coverage rule. It’s the most your plan will cover of a drug in a set time. For example, 60 tablets for a 30-day prescription. This helps make sure drugs are used safely.
Referral
A referral is when your primary care provider (PCP) gives you approval to see a specialist. When your PCP issues a referral, they share the reason for the recommendation with the specialist. They also help coordinate your visit, so you get the proper care.
Special Enrollment Period (SEP)
A time when you may be able to enroll in or change your Medicare plan if you:
- Lose your employer coverage
- Move to a new service area
- Get Extra Help for your prescription drugs
- Have other special circumstances
It’s also called a “special election period.”
Special Needs Plan (SNP)
A SNP is a type of Medicare Advantage plan (as in D-SNP, C-SNP, I-SNP). It provides more focused health care for specific groups of people, such as those who:
- Have both Medicare and Medicaid
- Live in a nursing home
- Have certain chronic medical conditions
Standard pharmacy
This is a pharmacy that has a contract with us but doesn’t offer preferred cost sharing.
Step therapy
This is a coverage rule. This is when you have to try a certain drug first before we cover a different one for the same condition.
For example:
If drug A and drug B both treat your condition, we may ask you to try drug A first.
If drug A doesn’t work, then we’ll cover drug B.
Aetna and CVS Caremark® are part of the CVS Health® family of companies.
Get member help
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Frequently asked questions by members
We know insurance is confusing. We’re here to help answer your questions.