AmeriHealth^® Rx PDP Option I

AmeriHealth Rx PDP is a prescription drug plan with a Medicare contract and is offered by QCC Insurance Company. AmeriHealth Rx PDP is administered by FutureScripts^® Secure, a pharmacy benefit management program, and is available throughout Pennsylvania and West Virginia.

AmeriHealth Rx PDP Option I
Monthly premium	$42.10
Deductible (what you pay before the plan starts to pay)	$320.00
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 until $2,930 coverage limit.
Coverage Gap (when you pay all drug costs until the catastrophic coverage begins)	You pay 86% Generic coverage and a discount on brand name drugs through the coverage gap until $4,700 TrOOP is paid by the member annually.
Catastrophic Coverage (starts when your total drug costs for the current year reach $4,700)	You pay the greater of $2.60/$6.50 or 5% coinsurance per prescription for the rest of the year. The plan pays the rest.

Enroll by mail

Download AmeriHealth Rx PDP Form Y0041_S2321_AHRx12_01 File & Use 09/13/2011.

Mail to:

AmeriHealth Rx PDP
Medicare Department
P.O. Box 41535
Philadelphia, PA 19101-1535

Enroll by phone

Please call Customer Service for AmeriHealth Rx PDP at 1-866-456-1695, seven days a week, 8 a.m. to 8 p. m. EST. (Speech- and hearing-impaired users should call 1-866-456-1683). However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to an answering machine.

Summary of Benefits

The Summary of Benefits tells you about some of the plan’s features. You should refer to the Summary of Benefits for:

• applicable conditions and limitations;
• premiums;
• cost-sharing (e.g., copayments, coinsurance, and deductibles);
• any conditions associated with receipt or use of benefits.

Download the AmeriHealth Rx PDP Summary of Benefits Y0041_S2321_AHRx12_11 CMS Approved 09132011.

Evidence of Coverage

The Evidence of Coverage is our contract with you. It explains your rights, benefits, and responsibilities as a member of our plan.

Download the AmeriHealth Rx PDP Evidence of Coverage Y0041_S2321_AHRx12_01 File & Use 09/13/2011.

Drug Formulary

A drug formulary is a list of generic and brand-name prescription drugs that are covered by the plan, are FDA-approved, and have been chosen for their reported medical effectiveness and value.

Download the AmeriHealth Rx PDP Formulary Y0041_S2321_AHRx12_06 File & Use 09/03/2011.

Contact us

For more information, please contact us.

Read some of the most frequently asked questions about the AmeriHealth Rx PDP .

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