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AmeriHealth^® Rx

New Jersey

AmeriHealth Rx is a Medicare-approved prescription drug plan (PDP) offered by AmeriHealth HMO Inc. AmeriHealth Rx is administered by FutureScripts^® Secure, a pharmacy benefit management program, and is available throughout New Jersey.

With AmeriHealth Rx, you have a choice of the following benefit options:

Option I

Monthly Premium: $28.60

Option I has a $125 annual deductible.

Before the total yearly drug costs (paid by the member and/or plan) reach $2,510, AmeriHealth Rx members will pay the following for prescription drugs:

• $5 generic at a retail pharmacy, 30-day supply
• $35 brand preferred at retail pharmacy, 30-day supply
• $50 non-brand preferred at retail pharmacy, 30-day supply

You pay 100 percent of drug costs at discounted prices through the coverage gap. After the member’s yearly true out-of-pocket costs (TROOP) reach $4,050, AmeriHealth Rx members will pay the greater of five percent coinsurance or $2.25 generic, and $5.60 brand copay thereafter.

Option II

Monthly Premium: $35.30

Option II provides a higher level of coverage than Option I. There is no deductible or coverage gap for generic drugs.

Before the total yearly drug costs (paid by the member and/or plan) reach $2,510, AmeriHealth Rx members will pay the following for prescription drugs:

• $10 generic at a retail pharmacy, 30-day supply
• $35 brand preferred at retail pharmacy, 30-day supply
• $50 non-brand preferred at retail pharmacy, 30-day supply

There is unlimited generic coverage through the coverage gap with a $10 copay. After total-out-of-pocket drug costs reach $4,050, AmeriHealth Rx members will pay the greater of five percent coinsurance or $2.25 generic, and $5.60 brand copay thereafter.

AmeriHealth Rx Plan Option Comparison Chart:

	AmeriHealth Rx Option I	AmeriHealth Rx Option II
Monthly Premium	$28.60	$35.30
Deductible (what you pay before the plan starts to pay)	$125	$0 Benefits start right away
Cost Sharing (what you and the plan pay in total covered prescription drug costs up to a certain level — the initial coverage limit)	For the first $2,510 in total drug costs, you pay $5 per generic, $35 per preferred brand, and $50 per non-preferred brand drugs on the formulary.	For the first $2,510 in total drug costs, you pay $10 per generic, $35 per preferred brand, and $50 per non-preferred brand drugs on the formulary.
Coverage Gap (when you pay all drug costs until the catastrophic coverage begins)	You pay 100% at discounted prices after yearly drug costs reach $2,510	Unlimited coverage for generic drugs with a $10 copay, or pay 100% at discounted prices for brand drugs after yearly drug costs reach $2,510
Catastrophic Coverage (starts after you have paid $4,050 out-of-pocket for covered drugs in a year)	You pay the greater of $2.25 per generic or $5.60 per brand-name drug, OR pay 5% coinsurance per prescription for the rest of the year. The plan pays the rest.	You pay the greater of $2.25 per generic or $5.60 per brand-name drug, OR pay 5% coinsurance per prescription for the rest of the year. The plan pays the rest.

For more complete information, see the Benefit and Plan Choices Brochure.

Download the 2008 AmeriHealth Rx Summary of Benefits or Evidence of Coverage, for more information on:

• applicable conditions and limitations;
• premium information;
• cost sharing information;
• information regarding conditions associated with receipt or use of benefits.

Definitions

Premiums
Premiums are the monthly charges you pay to participate in the plan. The monthly premium will vary depending on the plan you choose.

Deductible
This is the amount you pay before your plan starts paying your claims.

Coinsurance
A type of cost-share in which you pay a percentage.

Coverage Gap
“Coverage gap” describes when the plan does not contribute to drug costs, and you pay 100 percent for drugs until you reach a preset maximum.

If you have limited income and resources, you may qualify for low-income subsidy. When you join AmeriHealth Rx, 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
• Your State Medicaid Office
• 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.

Benefits listed here are effective January 1, 2008. Benefits, formulary, pharmacy and provider networks, premiums, and/or copays may change on January 1, 2009.

AmeriHealth Rx prospective members should call 1-800-898-3492 (TTY/TDD: 1-877-219-5457), seven days a week, 8 a.m. to 8 p.m., for questions related to the product.

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.