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AmeriHealth® Advantage

Product description

How AmeriHealth Advantage Works

AmeriHealth Advantage contracts with the Federal Government and is a Medicare prescription drug plan that is designed for people with Medicare who are interested in Standard Medicare Part D prescription drug coverage.

Anyone who is entitled to Medicare benefits under Part A or enrolled in Part B can join AmeriHealth Advantage. In addition, people who have both Medicare and Medicaid as well as limited incomes will receive additional help paying for prescription drugs. These beneficiaries will have lower cost sharing and will pay only a small amount for their prescription drugs.

Here is how the cost sharing will work for the Standard AmeriHealth Advantage Medicare Part D benefit:

If you have both Medicare and Medicaid as well as a Medicare Savings Program, you will pay no premium or deductible and have no gap in coverage.

To see if you qualify for extra help paying for prescription drugs, contact Medicare at 1-800-MEDICARE (TTY/TDD 1-877-486-2048) 24 hours a day, seven days a week; their state Medicaid office; or 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.

Learn more about the Download PDF low-income subsidy.

Here is how the cost sharing will work for the Standard AmeriHealth Advantage Medicare Part D benefit without the low-income subsidy:

Premiums (what you pay to participate in the plan)
Premiums are the monthly charges you pay to participate in the plan. The monthly premium will vary depending on where you live or if you qualify for assistance programs. For your convenience, you can either have your monthly premiums deducted automatically from your Social Security check or be billed by the plan.

Monthly Premiums (what you pay to participate in the plan)

For Pennsylvania and West Virginia: $28.60

Deductible (what you pay before benefits start)
This is the amount you pay before your insurance starts. In Medicare prescription drug plans (like AmeriHealth Advantage) that provide the Standard Medicare Part D benefit, the deductible is $295.

Coinsurance (how you share costs with the plan)
This is the term for splitting costs on a percentage basis. For example, with the Standard Medicare prescription drug coverage, you pay 25 percent of the drug costs and the plan pays 75 percent of the cost until the combined total reaches $2,700.

Coverage Gap (when you pay 100%)
“Coverage gap” describes when the plan makes no contribution to drug costs, and you pay 100 percent out-of-pocket for drugs until you reach a pre-set maximum. Medicare prescription drug plans use a formulary (a government-approved list of drugs that it covers), and when you use the plan’s network pharmacies you’ll have access to discounted drugs. That means you’ll still have access to discounts during the coverage gap.

After $4,350 Out of Pocket (when the plan pays most of the cost)
Once you’ve paid $4,350 out of your own pocket for drugs in a year, the plan pays most costs. You pay a small portion, such as 5 percent, or a small fixed amount for each prescription.

Here’s another way to look at the Standard drug benefit:

Steps:
AmeriHealth Advantage Rx Option I

Deductible

(what you pay before the plan starts to pay)

$295

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 $2,700 in total drug costs.

Coverage Gap

(when you pay all drug costs until reaching the catastrophic coverage begins)		 You pay 100% at discounted prices after yearly drug costs reach $2,700.

Catastrophic Coverage

(starts after you have paid $4,350 out of pocket for covered drugs in a year)		 You pay the greater of $2.40 per generic or $6.00 per brand-name drug, OR pay 5% coinsurance per prescription for the rest of the year. The plan pays the rest.

More information on AmeriHealth Advantage benefit options.

Need extra help with health plan and drug costs?

If you have limited income and resources, you may qualify for low-income subsidy. When you join AmeriHealth 65, 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

Benefits, formulary, pharmacy and provider networks, premiums, and/or copayments may change on January 1, 2010. Please contact AmeriHealth 65 for details.

Learn more about the Download PDF low-income subsidy.

If you live in Pennsylvania or West Virginia, AmeriHealth Advantage prospective members should call 1-866-456-1695 (TTY/TDD 1-866-456-1683), 8 a.m. to 8 p.m., seven days a week for questions related to the product.

Benefits, formulary, pharmacy and provider networks, premiums, and/or copays may change on January 1, 2010. Please contact AmeriHealth Advantage for details.

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.