Medicare Matters. Amerihealth 65 for medicare Beneficiaries

AmeriHealth® Rx

Pennsylvania and West Virginia

AmeriHealth Rx is a Medicare-approved prescription drug plan (PDP). offered by QCC Insurance Company. AmeriHealth Rx is administered by FutureScripts Secure, a pharmacy benefit management program, and available throughout Pennsylvania and West Virginia.

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

Option I

Monthly Premium: $39.80

Option I provides the standard Medicare Part D prescription drug benefit (with $275 annual deductible; 25% coinsurance from $276 to $2,510 in total yearly costs). After the member’s yearly out-of-pocket costs reach $4.050 TrOOP, AmeriHealth Rx members will pay the greater of 5% coinsurance or $2.25 generic and $5.60 brand copay thereafter.

Option II

Monthly Premium: $51.50

Option II provides a higher level of coverage than Option I. There is no deductible.

Before the total yearly drug costs (paid by the member and/or plan) reach $2,350, 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-preferred brand at retail pharmacy, 30 day supply

You pay 100% of drug costs at discounted prices through the coverage gap. After total-out-of-pocket drug costs reach $4,050, AmeriHealth Rx members will pay the greater of 5% 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

$39.80

$51.50

Deductible

(what you pay before the plan starts to pay)

$275

$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)

You pay 25%coinsurance per prescription up to $2,510 in total drug costs.

For the first $2,350 in total drug costs, you pay $10 per generic, $30 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

You pay 100% at discounted prices after yearly drug costs reach $2,350.

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/$5.60 per brand-name drug OR 5% coinsurance per prescription for the rest of the year. The plan pays the rest.

You pay the greater of $2.25 per generic/$5.60 per brand-name drug OR 5% coinsurance per prescription for the rest of the year. The plan pays the rest.

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

Download PDF 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% for drugs until you reach a pre-set 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/7 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.