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Frequently Asked Questions about AmeriHealth 65 NJ Rx HMO
1. How do I know if the medications I take are covered?
2. I travel a lot. What if I have an emergency?
3. Does AmeriHealth 65 NJ Rx HMO cover dental visits?
4. What resources do you have for managing health conditions like asthma?
5. Do I have to file claims with AmeriHealth 65 NJ Rx HMO?
6. I already have Medicaid and Original Medicare. Why join AmeriHealth 65 NJ Rx HMO?
7. Do I have to pick a primary care physician (PCP)?
9. What if I need to go outside the network area?
10. Do I need a referral to see a specialist?
11. Does AmeriHealth 65 NJ Rx HMO cover vision and hearing visits?
12. What if I have AmeriHealth 65 NJ Rx HMO coverage through my employer?
13. Do I qualify for low-income subsidy?
14. What is the drug formulary?
15. How do I receive benefits as a member with a drug formulary?
16. How my doctor know to prescribe a drug formulary medication?
How do I know if the medications I take are covered?
You can find the list of drugs covered by AmeriHealth 65 NJ Rx HMO on the plan’s 
drug formulary.
I travel a lot. What if I have an emergency?
You’re covered for emergency care, urgent care, or dialysis anywhere in the U.S. at the in-network benefit level. Not an emergency? You may use out-of-network doctors and hospitals at any time; you will just have to pay more than if you used an in-network provider.
Does AmeriHealth 65 NJ Rx HMO cover dental visits?
With AmeriHealth 65 NJ Rx HMO, you’re eligible for benefits to pay for routine dental exams and cleanings. Dental benefits are available through network providers only. Be sure to indicate your choice of primary dental office on your enrollment form.
What resources do you have for managing health conditions like asthma?
If you have asthma, diabetes, or another chronic condition, you can get the one-on-one support you need to manage your health through ConnectionsSM Health Management Programs. You’ll have access to a Health Coach whom you can talk to any time, day or night, seven days a week.
Do I have to file claims with AmeriHealth 65 NJ Rx HMO?
With our automatic claims filing, there is virtually no paperwork for you to worry about. In most cases, you simply present your AmeriHealth 65 NJ Rx HMO ID card.
I already have Medicaid and Original Medicare. Why join AmeriHealth 65 NJ Rx HMO?
With AmeriHealth 65 NJ Rx HMO, you’ll get more benefits and services than you have now with Original Medicare. And, you will keep your Medicaid coverage.
Do I have to pick a primary care physician (PCP)?
Yes. AmeriHealth 65 NJ Rx HMO is a managed care plan. That means all your health care goes through one main doctor (a PCP) whom you pick when you join. You’ll see this doctor for most medical care. If you need to go to a specialist or to the hospital, your primary care doctor must coordinate it, except for emergency care. There’s a good chance your current doctor is already in our network.
Which doctors can I see?
AmeriHealth 65 NJ Rx HMO has a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network.
What if I need to go outside the network area?
The use of non-plan providers, except for emergency care and out-of-area urgent care and renal dialysis, may result in you having to pay for services rendered. Neither AmeriHealth 65 NJ Rx HMO nor Medicare will pay for these services.
Do I need a referral to see a specialist?
Yes. Keep in mind that your primary care physician (PCP) coordinates all of your care except for emergencies. If you need to see a specialist, your PCP will give you a referral.
Does AmeriHealth 65 NJ Rx HMO cover vision and hearing visits?
With AmeriHealth 65 NJ Rx HMO, you’re covered for vision and hearing services — and can get reimbursed for eyewear and hearing aids.
What if I have AmeriHealth 65 NJ Rx HMO coverage through my employer?
If you have coverage through your former (or current) employer, Health and Welfare Fund, or an Association Group, your benefits may vary. Contact us for more information.
Do I qualify for low-income subsidy?
If you have limited income and resources, you may qualify for low-income subsidy. When you join AmeriHealth 65 NJ Rx HMO, 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 extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY 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 users should call, 1-800-325-0778; or
- Your State Medicaid Office.
Please note: In some cases, Medical Assistance copays will apply.
What is the drug formulary?
A formulary is a list of the drugs we cover. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy or through our network mail order pharmacy service, and other coverage rules are followed.
How do I receive benefits as a member with a drug formulary?
At a participating pharmacy, your level of benefits is higher when you use a drug formulary medication, meaning you’ll only be responsible for a copay which varies whether you purchase a generic or brand formulary medication. Your benefit for a non-preferred medication will result in a higher copay. A mail order feature is also available for long-term drug purchases.
How will my doctor know to prescribe a drug formulary medication?
Have your doctor review the formulary guide to determine if your prescription medications are on the formulary; you may already be taking drug formulary medications. If you are, you will only pay your copays for these drugs. If you are prescribed covered drugs that are not on the drug formulary, ask your doctor to review the Formulary Pocket Guide to see if another drug on the formulary, such as a generic equivalent or therapeutic alternative, can be used to treat your condition. If, after discussion with your doctor, he/she does not prescribe a drug formulary medication, your covered prescription will be subject to the higher non-preferred copay.
You must continue to pay your Medicare Part B premium.
The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions.
Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
- Your State Medicaid Office.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor AmeriHealth 65 NJ HMO will be responsible for the costs.
Please contact AmeriHealth 65 HMO for more information.
In lots of cases, your prescriptions are covered under AmeriHealth 65 NJ HMO, AmeriHealth Rx PDP if they are filled at a network pharmacy or through our mail-order pharmacy service. There are thousands of network pharmacies, including:
- national chain and independent retail pharmacies
- long-term care and home-infusion pharmacies
- Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies
Website last updated: 12/30/11
Y0041_HNS_12_301a Pending CMS Approval
