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Frequently Asked Questions about AmeriHealth Rx PDP
1. Who can get Medicare Part D prescription drug coverage?
3. When can I sign up for my Medicare Part D prescription drug coverage?
5. Do I have to sign up for Medicare Part D prescription drug coverage?
6. What if I have prescription drug coverage from an employer or union?
8. What is the drug formulary?
9. How do I receive benefits as a member with a drug formulary?
10. How will my doctor know to prescribe a drug formulary medication?
Who can get Medicare Part D prescription drug coverage?
Any person with Medicare is eligible for the Medicare Part D prescription drug coverage. You must be entitled to Medicare Part A (hospital care) and/or be eligible for Medicare Part B (medical care). And, you must join a prescription drug plan (PDP) that is available where you live.
I don’t take any prescription drugs now. Why would I want to join a Medicare prescription drug plan?
Even if you don’t use prescription drugs now, you may need prescription drugs in the future. Medicare prescription drug coverage is important since medical practice has come to rely more and more on new drug therapies.
When can I sign up for my Medicare Part D prescription drug coverage?
Medicare Part D prescription drug coverage began on January 1, 2006. Many people with Medicare have already signed up for the coverage by joining a prescription drug plan. If you have not already joined a prescription drug plan, you may do so each year during the time period of October 15 through December 7. You will be able to join a plan, drop a plan, or change plans during that time. Your options are limited at other times of the year.
I will soon turn 65 and I want to sign up for Medicare Part D prescription drug coverage, do I have to wait until October 15 through December 7?
No. If you are turning 65 you may join a Medicare prescription drug plan during the time that is called your Initial Coverage Election Period for both Medicare Part B and Medicare Part D. This period includes the three months before your birth month, your birth month, and three months after your birth month.
Do I have to sign up for Medicare Part D prescription drug coverage?
No. You can choose to join. However, if you do not join a Medicare prescription drug plan when you first become eligible for Medicare, you will pay a penalty when you do decide to enroll in a Medicare prescription drug plan. And, you will pay the penalty each month for as long as you stay in a Medicare prescription drug plan. For most people, joining as soon as possible means you pay your lowest monthly premium. You can also feel secure that you will be protected from any unforeseen, catastrophic drug expenses.
What if I have prescription drug coverage from an employer or union?
If your employer or union plan covers as much as or more than a Medicare prescription drug plan, you can:
- Keep your current drug plan. If you join a Medicare prescription drug plan sometime in the future, you will not pay a monthly penalty.
- Drop your current drug plan and join a Medicare prescription drug plan. However, you may not be able to get back into your employer or union drug plan if you change your mind.
If your employer or union plan covers less than a Medicare prescription drug plan, you can:
- Keep your current drug plan and join a Medicare prescription drug plan to give you more complete prescription drug coverage.
- Just keep your current drug plan. However, if you join a Medicare prescription drug plan later, you will have to pay a monthly penalty.
- Drop your current drug plan and join a Medicare prescription drug plan. However, you may not be able to get back into your employer or union drug plan if you change your mind.
My income is very limited. It will be hard for me to pay the premiums and deductible in a Medicare prescription drug plan. Is there any extra help for me?
People with limited income and resources (including your savings, stocks and bonds, but not counting your home or car) may be able to get extra help paying for prescription drugs. You may get an application in the mail from the Social Security Administration (SSA) for extra help paying for a Medicare prescription drug plan. It is very important that you fill out this application and return it to the SSA. If you don't get an application in the mail, and you think you may qualify for this help, call the SSA at 1-800-772-1213 (TTY 1-800-325-0778.) You can also visit www.socialsecurity.gov on the web. SSA’s application process provides you with the quickest decision. You can also go to your State Medical Assistance Office to 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
