Brand-name drug: Drug approved by the U. This phase kicks in after a patient reaches the out-of-pocket maximum in the Coverage Gap Phase. Case manager: A healthcare professional who helps coordinate patient care. Department of Health and Human Services program that provides matching funds to states for uninsured low-income children not covered by Medicaid. Claim: An invoice sent by a healthcare provider to a health insurance company detailing the services received.

See Value-Based Insurance Design. Coinsurance: Requirement for patients to pay a percentage of costs of covered services. Coordination of benefit: A process used by insurers to determine which plan has responsibility for which charges; used when a patient has more than one policy or type of coverage. Commercial insurance: Health insurance provided by a private non-government company not Medicare.

Co-payment co-pay : A fixed amount paid by patients for services or prescriptions covered by health insurance. Co-pay accumulator: See Accumulator adjustment programs. Co-pay coupon: A discount coupon issued by a drug manufacturer that can be used to offset the cost of the drug. See Drug coupon program. Co-pay foundation: A program run by an independent nonprofit organization that helps patients meet their co-pay expenses based on financial need. Cost-sharing Reduction CSR : A discount that lowers the amount of out-of-pocket costs that patients need to pay for deductibles, co-payments and coinsurance.

Coverage: The benefits included as part of a health insurance plan. See Donut hole. Creditable coverage: Insurance that is comparable to that provided by Medicare Part D e. Dependent: A person—usually a spouse or child—of an insured individual who is eligible for insurance coverage. See Coverage Gap. Drug formulary: A list of specific prescription drugs that are covered by a health insurance plan, which includes drugs that are preferred because of efficacy and cost.

See Formulary, Preferred drug list. Employer Sponsored Commercial Insurance: Health insurance that is provided through the workplace. Exclusion or limitation: A provision within a health insurance plan that denies coverage for certain conditions or services.

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Fail first: Insurance policies that mandate that the cheapest drug must be tried first, regardless of which drug the physician prescribed. See Step therapy.

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Family and Medical Leave Act FMLA : A federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year without fear of losing their jobs. Employers that are covered by FMLA must maintain health benefits for eligible workers as if they were working. Financial navigator: An individual who helps patients with health insurance coverage and with locating financial assistance when needed. See Patient navigator. Financial toxicity: Unmanageable out-of-pocket costs related to medical treatment, that cause stress, may impact adherence with therapy and impact patient outcomes.

Formulary transparency: A clear and easily understood listing of all drugs in a health plan formulary, along with their costs. Generic drug: An exact copy of a brand-name prescription drug, i. Health insurance: A way to pay for healthcare. It protects patients from paying the full costs of medical services when they are sick or injured. There are different types of health insurance.

Some kinds of health insurance are provided by private insurers, employers or through the federal government. Health insurance marketplace exchanges : Organizations in each state where health insurance meeting certain benefits and cost criteria can be purchased.

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Health insurance network: See Affiliated provider, In-network care, In-network provider. Department of Health and Human Services HHS : The federal agency that regulates and administers health and human service programs, and promotes advances in medicine, public health and social services. The U.

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Health Maintenance Organization HMO : A healthcare system comprising a network of providers and facilities, in which costs are managed centrally and gatekeepers are used. See Managed care, Gatekeeper. Health savings account: A type of account for setting aside pre-tax income to pay for medical expenses. See Affiliated provider, In-network provider. In-network provider: A healthcare provider who is contracted with a health insurance plan to provide services to policy holders at pre-negotiated rates.

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See Affiliated Provider, In-network care. Initial Coverage Phase: In Medicare Part D, the period after the deductible is met, in which the patient pays the prescribed share of cost for medications; when the maximum is reached, the patient enters the Coverage Gap Phase. Insurance cap: The maximum amount a health insurance plan will pay in total benefits.

Legend drug: A drug approved by the U. Food and Drug Administration that can only be obtained with a prescription.

Lifetime limit: A cap on the total lifetime benefits a patient can get from their insurance company. After a lifetime limit is reached, the insurance plan will no longer pay for covered services. Mail order pharmacy: A pharmacy that ships prescription medications to customers. Manufacturer-sponsored patient assistance programs PAP : Programs in which drug companies provide low-income individuals with access to medications at reduced, or no cost. Medically necessary: Required to diagnose, prevent or treat a condition, illness or injury. Medicare: Federal health insurance program for U.

Can also be combined with Part D prescription coverage. Medicare Savings Program MSP : A federal program that assists eligible low-income individuals with medical expenses such as premiums, deductibles, co-pays and coinsurance; administered by the states. See Medigap policy.

Minimum Essential Coverage: An insurance plan that meets the Affordable Care Act requirement for having health coverage. Narrow network: Health plans with lower premiums but a more limited choice of providers than typical plans. Non-formulary drugs: Drugs that are not on a healthcare plan's approved list. See Drug formulary, Formulary, Preferred drug list. Non-preferred medication: High-cost medications with higher co-pay amounts and co-insurance obligations; often not on a formulary, and require prior authorization. Patients typically pay higher out-of-pocket costs to see non-preferred providers.

Non-prescription drug: A drug that can be purchased without a prescription. See Over-the-counter OTC. Ombudsman: A person who helps resolve problems between an individual and an institution. Open Enrollment: A specific period of time during which people can add, drop or change their health insurance coverage. Part D prescription coverage typically needs to be purchased separately. See Traditional Medicare. See Out-of-network provider. Out-of-network provider: A healthcare provider that is not contracted with the health insurance plan, and whose services are covered by the insurance plan minimally, if at all.

See Out-of-network care. Out-of-pocket OOP costs: Costs for medical care that are not covered by insurance.

Out-of-pocket maximum: A cap on out-of-pocket costs within a defined coverage period; when the out-of-pocket maximum is met, the health insurance plan begins paying for covered services. See Advocate. Patient assistance program PAP : A program offered by a drug manufacturer to help low-income patients obtain free or reduced-cost medication.

See Pharmaceutical patient assistance program. Patient consent: Patient permission for disclosure of personal information. Patient navigator: An individual who helps guide patients through the healthcare system, often assisting with locating financial and logistical e. See Financial navigator. Payer of last resort: The insurer who is responsible for paying costs of care for Medicaid beneficiaries, either Medicaid or another insurer.

See Medicare Part D. Pharmaceutical patient assistance program: See Patient assistance program.

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Preauthorization: Determination by a health insurance plan that a medication or service is medically necessary prior to approving it for payment. Precision medicine: Medical care that is tailored to genetic, environmental and lifestyle factors. Make sure you use adequate clothing and sun screen, and limit sun exposure.

Notify y our doctor of any sunburns or skin blisters. Stinging, burning, or redness may occur at onset of treatment. If these effects worsen or persist, or if new or worse symptoms occur, tell your doctor immediately.