• Medicare Part D

• AmeriHealth 65

• AmeriHealth 65 Basic

• AmeriHealth Rx (NJ)

• AmeriHealth Rx (PA/WV)

• AmeriHealth Advantage (PA/WV)

• Group Plans

• Disclaimer

AmeriHealth 65^® Basic

Product description

$0 Premium — effective January 1, 2008

What’s the premium?

The AmeriHealth 65 Basic Plan has NO monthly plan premium ($0). You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or any other third party.

What’s covered?

With AmeriHealth 65 Basic, you’re covered for many health care services you may need, just as you would be with Original Medicare.

These services include:

Primary care doctor visits Skilled nursing facility stays Specialist visits Home health care Inpatient hospital care Hospice care Inpatient mental health care Chiropractic care Outpatient surgery Podiatry Outpatient rehabilitation services Durable medical equipment Outpatient mental health care Prosthetic devices Outpatient substance abuse care Diabetes self-monitoring training and supplies Ambulance services Diagnostic tests, X-rays, and lab services Emergency medical care within the United States Radiation therapy Urgently needed care within the United States Preventive health services Health and wellness programs Prescription drug coverage

You’re also covered for many health care services that Medicare doesn’t cover, such as:

• unlimited (non-emergency) roundtrip transportation to plan approved providers;
• eyewear benefit;
• routine hearing exams and hearing aids;
• AmeriHealth Healthy Lifestyles^SM programs (such as weight loss and smoking cessation).

What do I pay for prescription drugs?

The only costs are a $1 copay for generic drugs and a $3.10 copay for brand drugs.

For complete details of covered services, copays, and deductibles for this AmeriHealth 65 Basic plan, see the Summary of Benefits or Evidence of Coverage.

Benefits listed here are effective January 1, 2008. Benefits, formulary, pharmacy, network, premium, and/or copays/coinsurance may change on January 1, 2009. Please contact AmeriHealth 65 Basic for details.

Where can I get more information?

Call us toll-free: 1-800-898-3492 (TTY/TDD 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week.

If you have limited income and resources, you may qualify for low-income subsidy. When you join AmeriHealth 65 Basic, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. If you qualify, your drug costs will also be lower.

You can see if you qualify for a low-income subsidy by calling:

• 1-800-MEDICARE (1-800-633-4227) (TTY/TDD: 1-877-486-2048), 24 hours a day, seven days a week
• Pennsylvania Office of Medical Assistance Programs (Medicaid) at 717-787-1870
• The Social Security Administration at 1-800-772-1213 (TTY/TDD: 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday

Please note: In some cases, Medical Assistance copays will apply.

Learn more about the low-income subsidy.

Best Available Evidence Policy

Early in 2006, a number of factors contributed to the problem of incorrect cost-sharing levels for full-benefit dual eligible’s and other LIS eligible individuals. The purpose of this link is to provide a member with information on CMS best available data policy.

In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. To address these situations, CMS created the best available evidence (BAE) policy. This policy requires Plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate.

Learn more about the Best Available Evidence Policy.