Prescription Drug Plan Terms and What They Mean
Evidence of Coverage (EOC) and Disclosure Information:
Evidence of Coverage (EOC), along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.
A type of coverage determination that, if approved, allows you to get a drug that is not on your SilverScript plan 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 requires you to try another drug before receiving the drug you are requesting (a Step Therapy exception), or the plan limits the quantity or dosage of the drug you are requesting (a Quantity Exception).
Explanation of Benefits (EOB):
A statement you receive for every month you use your Medicare Part D prescription drug benefits. This statement is sent by the plan and provides complete information about the health or prescription drug services you've received, including any payments made and any costs you are responsible for paying. It is important to remember that the EOB is not a bill, but a statement provided by your plan for your convenience.
A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and cost-sharing.
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, a “generic” drug works the same as a brand name drug and usually costs less.
A grievance is a complaint or dispute made by a member to express dissatisfaction with any aspect of operations, activities or behavior of a Part D sponsor or related agent (e.g. Network Pharmacy). Grievances are not intended to cover dissatisfaction with coverage and late enrollment penalty (LEP) determinations, but may include complaints related to the timeliness of processing them. Grievances must be filed within 60 days of the qualifying event and may be filed regardless of whether the member asks for corrective action.
Health Insurance Portability and Accountability Act (HIPAA):
HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following:
- Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs.
- Reduces health care fraud and abuse.
- Mandates industry-wide standards for health care information on electronic billing and other processes.
- Requires the protection and confidential handling of protected health information.
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