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AmeriHealth® Rx

Pennsylvania and West Virginia

AmeriHealth Rx contracts with the Federal Government and is offered by QCC Insurance Company. AmeriHealth Rx is administered by FutureScripts® Secure, a pharmacy benefit management program, and is available throughout Pennsylvania and West Virginia.

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

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Option I

Monthly Premium: $54.30

Option I provides the standard Medicare Part D prescription drug benefit (with $295 annual deductible; 25% coinsurance from $295.01 to $2,700 in total yearly costs). After the member’s yearly true out-of-pocket (TROOP) costs reach $4,350, AmeriHealth Rx members will pay the greater of 5% coinsurance or $2.40 generic and $6.00 brand copayment for the rest of the year.

Option II

Monthly Premium: $58.90

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 $2,700, AmeriHealth Rx members will pay the following for prescription drugs:

  • $7 generic at a retail pharmacy, 30-day supply
  • $30 brand preferred at retail pharmacy, 30-day supply
  • $70 non-preferred brand at retail pharmacy, 30-day supply
  • 33% for specialty drugs at retail pharmacy, 30-day supply

After you reach $2700, you pay 100% of drug costs at discounted prices through the coverage gap. After your total-out-of-pocket drug costs reach $4,350, AmeriHealth Rx members will pay the greater of 5% coinsurance or $2.40 generic and $6.00 brand copay thereafter.

AmeriHealth Rx Plan Option Comparison Chart

 

AmeriHealth Rx Option I

AmeriHealth Rx Option II

Monthly Premium

$54.30

$58.90

Deductible

(what you pay before the plan starts to pay)

$295

$0
Benefits start right away

Initial Coverage Phase

(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.

For the first $2,700 in total drug costs, you pay $7 per generic, $30 per preferred brand and $70 per non-preferred brand, and 33% for specialty 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 $2,700.

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/$6.00 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 $2.40 per generic/$6.00 per brand-name drug OR 5% coinsurance per prescription for the rest of the year. The plan pays the rest.

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

Download the Download PDF 2009 AmeriHealth Rx Summary of Benefits or Download PDF 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.

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 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 may be able to get extra help to pay for your prescription drug premium and costs. To see if you qualify for getting extra help, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY/TDD machine users should call 1-877-486-2048, 24 hours a day/7 days a week);

  • The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778; or

  • Your State Medicaid Office.

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

Benefits listed here are effective January 1, 2009. Benefits, formulary, pharmacy and provider networks, premiums, and/or copays may change on January 1, 2010.

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.

Learn more about the Download PDF 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 members with information on CMS Best Available Evidence 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.

The AmeriHealth Rx Medicare contract is renewed annually. The availability of coverage beyond the end of the current contract year is not guaranteed.