2015 · For 2015, AmeriHealth 65 Preferred HMO received the following Overall Star Rating from...

Individual health plan options for people with Medicare

Y0041_H3156_AH_15_19954 Approved (9/22/2014) 4644(10/14)BKV4

2015AmeriHealth 65® HMO Plan Information

Questions? Call AmeriHealth New Jersey at

Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

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Connect with us on Facebook: facebook.com/amerihealthmedicare

1-800-898-3492 (TTY/TDD: 711)

AmeriHealth HMO, Inc. is an HMO plan with a Medicare contract. Enrollment in AmeriHealth HMO, Inc. depends on contract renewal.

Benefits underwritten or administered by AmeriHealth HMO, Inc.

Contents

Introduction

Multi-language insert & Plan ratings

Terms to know

Benefits at a glance

Top 100 drugs covered

Ready to enroll?

Summary of benefits

Thank you. We appreciate your interest in AmeriHealth New Jersey. We look forward to serving you as

one of the many members who’ve chosen us for our stability, reliability, and large area

network of preferred doctors and hospitals.

This booklet provides you with information on our AmeriHealth 65® HMO plans. Take a few

minutes to look through it and decide which plan best fits your needs and budget. Of

course, you can call us with any questions about plan coverage, including monthly

premiums, copays, and deductibles.

We’ve included an enrollment form for your convenience. Simply complete the form and

return it in the postage-paid reply envelope provided. Or, you can enroll online.

Thanks again for requesting this information and for choosing AmeriHealth New Jersey.

Let’s get started

Get the plan that’s right for you.

It’s as easy as 1-2-3.3 simple steps are all it takes to find a Medicare plan that fits your budget, needs, and lifestyle.

Learn about the plans

we offer

1Compare

benefits, cost-sharing, and premiums

2Enroll in the plan you want

3

Medicare Advantage Plans: These plans are not paid through Original Medicare, they are offered by private insurance companies that are contracted through the Federal Medicare program. Your health care bills are paid by the insurance company. The plans are obligated to offer the same level of coverage as Original Medicare, except for hospice care, and may include prescription drug coverage. Medicare Advantage plans are not Medicare Supplement plans.

Medicare Supplement Plans (Medigap): With this option, you remain enrolled in Original Medicare. When you buy a Medicare Supplement plan from a private insurance company, Original Medicare will pay its share of costs for covered services, then your supplement plan will pay its share. These plans do not include prescription drug coverage. While your monthly premium may be higher than a Medicare Advantage plan, many people choose them for lower copays, deductibles, and coinsurance.

New Jersey residents can also get assistance with their drug costs through the state’s Pharmaceutical Assistance to the Aged and Disabled (PAAD) program.A PAAD beneficiary must be a New Jersey resident; be 65 or older, or at least 18 and receiving Social Security Title II Disability benefits; and have an annual income for 2014 of less than $26,130 if single or less than $32,037 if married. PAAD beneficiaries must be enrolled in a Medicare Part D Prescription Drug Plan in New Jersey. Medicare Advantage participants must have a Medicare Advantage with Prescription Drug Plan (MAPD) and PAAD will contribute up to the regional benchmark amount towards the prescription portion of their total premium.

PAAD will pay the monthly premium for certain standard Part D plans with a monthly premium at or below the regional benchmark or standard/enhanced plans up to $10 above the benchmark amount that has no deductible. These plans will cover medically necessary prescription medications under Medicare Part D. The Federal Medicare plan and/or PAAD will pay any costs above the PAAD copayment of $5 for each covered generic drug or $7 for each covered brand-name drug, including premiums. However, if a Medicare Part D plan does not pay for a medication because the drug is not on its formulary, PAAD beneficiaries will have to switch to a drug on their Part D plan’s formulary or their doctor will have to request an exception due to medical necessity directly to their Part D plan.

Medicare Advantage participants must add a prescription benefit to their coverage, and PAAD will contribute up to the regional benchmark amount towards the prescription portion of their total premium. To find out which basic Part D plans in New Jersey for which PAAD pays the monthly premium, please call 1-800-792-9745.

Because Original Medicare won’t cover all of your health care costs, here are

two types of plans that help you pay the rest.Let’s first take a look at the two types of plans available to you that will

help with the costs that Original Medicare leaves you to pay.

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Multi-language insert Plan ratings

• _______• _______• _______• _______

Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-898-3492. Someone who speaks English/Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-898-3492. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 我们提供免们的翻们服们，们助们解答们于健康或们物保们的任何疑们。如果们需要此翻们服们，们致们1-800-898-3492。我们的中文工作人们很们意们助们。们是一们免们服们。

Chinese Cantonese: 们對我們的健康或藥物保險可能存有疑問，们此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-800-898-3492。我們講中文的人員將樂意们们提供幫助。這是一項免費服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-898-3492. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-898-3492. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-898-3492 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-898-3492. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화1-800-898-3492 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.

Y0041_HNS_13_2343 Accepted 09262012

Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-898-3492. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic: األدویةجدولأوبالصحةتتعلقأسئلةأيعنلإلجابةالمجانیةالفوريالمترجمخدماتنقدمإنناماشخصسیقوم3492-898-800-1علىبنااالتصالسوىعلیكلیسفوري،مترجمعلىللحصول. لدینا

العربیةیتحدث مجانیةخدمةھذه. بمساعدتك .

Hindi: हमारे स्वास्थ्य या दवा क� योजना के बारे म� आपके �कसी भी प्रश्न के जवाब देने के �लए हमारेपास मुफ्त दभुा�षया सेवाएँ उपलब्ध ह�. एक दभुा�षया प्राप्त करने के �लए, बस हम� 1-800-898-3492 परफोन कर�. कोई व्यिक्त जो �हन्द� बोलता है आपक� मदद कर सकता है. यह एक मुफ्त सेवा है.

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-898-3492. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-898-3492. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-898-3492. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-898-3492. Ta usługa jest bezpłatna.

Japanese: 们社の健康健康保们と们品们方们プランに们するご質問にお答えするために、無料の通们サ们ビスがありますございます。通们をご用命になるには、1-800-898-3492にお電話ください。日本語を話す人者が支援いたします。これは無料のサ们ビスです。

AH6228 (9/13)

1. An Overall Star Rating that combines all of our plan's scores.

2. Summary Star Rating that focuses on our medical or our prescription drug services.

• How our members rate our plan's services and care;

• How well our doctors detect illnesses and keep members healthy;

• How well our plan helps our members use recommended and safe prescription medications.

Image description. 3.5 Stars End of image description.

3.5 Stars

Image description. 4 Stars End of image description.

Health Plan Services: 4 Stars Image description. 3.5 Stars End of image description.

Drug Plan Services: 3.5 Stars

Image description. 5 stars End of image description.




Image description. 1 star End of image description.

The number of stars shows how well our plan performs.

excellentabove averageaveragebelow averagepoor

AmeriHealth 65 Preferred HMO - H3156

2015 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality andperformance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these StarRatings to compare our plan's performance to other plans. The two main types of Star Ratings are:

Some of the areas Medicare reviews for these ratings include:

For 2015, AmeriHealth 65 Preferred HMO received the following Overall Star Rating from Medicare.

We received the following Summary Star Rating for AmeriHealth 65 Preferred HMO's health/drug plan services:

Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. at 800-898-3492 (toll-free) or711 (TTY), from October 15 to December 7. Our hours of operation for the rest of the year are Monday throughFriday from 8:00 a.m. to 8:00 p.m. Eastern time.

Current members please call 866-569-5190 (toll-free) or 711 (TTY).

*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to thenext.

Y0041_H3156_AH_15_23883 Accepted 10/15/2014

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Benefits at a glance

AmeriHealth 65® Preferred HMO offers low copays and a low monthly premium. All AmeriHealth 65 Preferred HMO plans provide access to over 29,000 doctors and 60 hospitals in the AmeriHealth New Jersey network!

Questions? Call AmeriHealth New Jersey at

Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Or visit us online at amerihealthmedicare.com

Connect with us on Facebook: facebook.com/amerihealthmedicare

1-800-898-3492 (TTY/TDD: 711)

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Y0041_H3156_AH_15_20496 Approved (9/22/2014)

If money matters, this budget-friendly plan may be right for you.

How to pick a plan:

If money matters, this budget-friendly plan may be right for you.

How to pick a plan:

With AmeriHealth 65 Preferred HMO you get:

• Optional medical and prescription drug coverage

• Network of 29,000 doctors, 60 hospitals, and 2,300 dentists.

• Vision, dental, and hearing benefits

• 24-hour access to a registered nurse

• Worldwide coverage for emergency and urgently needed care

• Fitness membership

You’ll also have access to our Healthy LifestylesSM Solutions:

• Nursing Hotline — Access to nurses 24/7 for case management and chronic diseases.

• Health Coach — 24/7 access to personalized help from a Health Coach in coordinating care and reaching health goals.

• Membership in the SilverSneakers®* fitness program.

*SilverSneakers is a program of Healthways, Inc.


Benefits underwritten or administered by AmeriHealth HMO, Inc.The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.



2015 APPLICATION CHECKLIST:

DOUBLE-CHECK to be sure you complete all information that applies to you. Missing information could delay your enrollment.

CHOOSE A PRIMARY CARE PHYSICIAN (if required) and include the 10-digit physician code.

SIGN AND DATE the Individual Enrollment Election Form.

KEEP THE PINK COPY of the form for yourself. This will prove your membership in the event your ID card is delayed.

Choosing a Plan: What you need to know• Most Medicare Advantage (MA) HMO and PPO plans offer a choice

of medical-only or medical plus Part D prescription drug options.

• If you are considering an MA plan — and you want prescription drug coverage — you should select an MA plan with a Part D prescription drug option.

• You may not be enrolled in more than one MA plan at any given time, or enrolled in a medical-only plan and a stand-alone Part D prescription drug plan at the same time. If you require both medical and prescription coverage, you must select an MA plan with a prescription drug plan from one MA organization.

• If you enroll in multiple MA plans during the Annual Election Period, the last enrollment request you make during that period will be considered the plan into which you intend to enroll.

If you enroll in one of our MA plans and are currently enrolled in a STAND-ALONE Part D plan, you will be disenrolled from the Part D plan.

2015 APPLICATION CHECKLIST:

DOUBLE-CHECK to be sure you complete all information that applies to you. Missing information could delay your enrollment.

CHOOSE A PRIMARY CARE PHYSICIAN (if required) and include the 10-digit physician code.

SIGN AND DATE the Individual Enrollment Election Form.

KEEP THE PINK COPY of the form for yourself. This will prove your membership in the event your ID card is delayed.

Choosing a Plan: What you need to know• Most Medicare Advantage (MA) HMO and PPO plans offer a choice

of medical-only or medical plus Part D prescription drug options.

• If you are considering an MA plan — and you want prescription drug coverage — you should select an MA plan with a Part D prescription drug option.

• You may not be enrolled in more than one MA plan at any given time, or enrolled in a medical-only plan and a stand-alone Part D prescription drug plan at the same time. If you require both medical and prescription coverage, you must select an MA plan with a prescription drug plan from one MA organization.

• If you enroll in multiple MA plans during the Annual Election Period, the last enrollment request you make during that period will be considered the plan into which you intend to enroll.

If you enroll in one of our MA plans and are currently enrolled in a STAND-ALONE Part D plan, you will be disenrolled from the Part D plan.

Y0041_H3156_AH_15_20494 Approved (8/26/2014)

This quick list of Medicare-related terms will help you better understand the information in this Plan Information Book.

Terms to know:

Deductible:The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

Coinsurance: An amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

Copayment: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

Premium: The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Network: “Provider” is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the state to provide health care services. We call them “network providers” when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as “plan providers.”

AmeriHealth HMO, Inc. is an HMO plan with a Medicare contract. Enrollment in Ameri-Health HMO, Inc. depends on contract renewal.


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Y0041_H3156_AH_15_20961 Approved (9/22/2014)

AmeriHealth 65 Preferred HMO has a $6,700 out-of-pocket maximum for 2015. That means you will never have to pay more than $6,700 out of your own pocket for covered health-related expenses you may incur above and beyond your monthly premium (expenses like deductibles and copayments).

* All AmeriHealth 65 Preferred HMO members must use in-network hospitals and physicians with the exception of emergent or urgently needed care; referrals required for most services.

**For urgently needed care outside of the United States, the Emergency Room copayment will apply. † Please see the enclosed Summary of Benefits for additional dental benefits.

You must continue to pay your Medicare Part B premium. Benefits underwritten or administered by AmeriHealth HMO, Inc.

Service category AmeriHealth 65® Preferred HMO*

Monthly plan premium

Region I Region II Region III Medical only $120.00 $40.00 $55.00 Medical with Rx $147.00 $62.00 $87.00

Primary Care Physician (PCP) Visits $20 copay

Specialist Visits $50 copay

Emergency Room (ER) $65 copay (not waived if admitted)

Urgent Care** $35 in-network Urgent Care Centers ($20 for PCP; $50 for Specialist)

Worldwide Coverage** Emergency care and urgently needed care are covered worldwide

Outpatient Surgery $100 Ambulatory Surgical Center $350 Outpatient Hospital Facility

Inpatient Hospital $270/day for days 1-7, $1,890 maximum per stay; unlimited days per admission

Fitness Program SilverSneakers®

Preventive Dental Care $0 copay for exams and cleanings once every 6 months†

Vision Care $50 copay for routine eye exam; Up to $100 for eyewear every 2 years

Hearing Services $50 copay for routine hearing exams; Up to $500 for 2 hearing aids every 3 years

Prescription drugs (optional)

Deductible $320 for brand prescription drugs No deductible for generic tier 1 and tier 2 drugs

Copay $4 preferred generic/$9 non-preferred generic/$45 preferred brand/$95 non-preferred brand/25% coinsurance specialty drug

Initial Coverage Limit $2,960 in total drug cost

Coverage Gap You pay 65% of generic drug costs and 45% of brand-name drug costs until you reach $4,700

Catastrophic You pay the greater of $2.65 generic and $6.60 brand or 5% coinsurance after reaching $4,700 catastrophic trigger

Mail Order (90-day supply) $8 preferred generic/$18 non-preferred generic/$90 preferred brand/$190 non-preferred brand/25% coinsurance specialty drug


AmeriHealth 65 HMO contract with CMS is renewed annually and the availability of coverage beyond the end of the current contract year is not guaranteed. AmeriHealth 65 HMO can choose to not renew its contract with CMS and CMS may also refuse to renew the contract, thus resulting in termination or non-renewal. This may result in termination of the beneficiary’s enrollment in their plan. In addition, the plan sponsor may reduce its service area and no longer offer services in the area where the beneficiary resides.

To join an AmeriHealth 65 HMO plan, you must have Medicare Part A and Part B. Please contact AmeriHealth HMO, Inc. for details. You may be enrolled in only one Part D Medicare prescription drug plan at a time. If you are enrolled in a Medicare Advantage (MA) coordinated care (HMO or PPO) plan or an MA Private Fee-for-Service (PFFS) plan that includes Medicare prescription drugs, you may not enroll in a stand-alone Part D prescription drug plan unless you disenroll from the HMO, PPO, or MA PFFS plan.

To join AmeriHealth 65 HMO you must live in the AmeriHealth 65 HMO service area (Atlantic, Bergen, Burlington, Camden, Cape May, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex, Union, and Warren counties, NJ). Enrolled members must use AmeriHealth 65 HMO plan providers except for in- or out-of-network emergencies or out-of-area urgent care and renal dialysis services within the United States. If you obtain routine care from out-of-network providers neither Medicare nor AmeriHealth 65 HMO will be responsible for the costs.

Please note: The federal government will not allow us to accept people with End-Stage Renal Disease (ESRD) unless converting from AmeriHealth HMO, Inc. individual or employer group coverage during their initial coverage election period, or if their current plan stops providing coverage in their area. However, should you develop ESRD while a member of AmeriHealth 65 HMO, you cannot be disenrolled for that reason.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may not change from one year to the next. You may receive prescription drugs shipped to your home through our network mail order delivery program and have the option of signing up for automated mail order delivery. Usually a mail-order pharmacy order will get to you in no more than 14 days. If we anticipate a delay in shipment of more than 14 days for any reason, we will call you within three business days of receiving and logging your prescription. If you should not receive your prescription drugs, please call FutureScripts Secure at 1-888-678-7015, 7 days a week, 24 hours a day. Or, you can visit our website at www.amerihealthmedicare.com. Medicare beneficiaries may also enroll in AmeriHealth 65 HMO through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.cms.gov. For more information, contact AmeriHealth 65 HMO at 1-800-898-3492 (TTY/TDD: 711).

This information is available for free in other languages. Please call our Customer Service number at 1-866-569-5190, seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30 your call may be sent to voicemail.

Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente al 1-866-569-5190, los siete días de la semana, 8 a.m. - 8 p.m. (Los usuarios de TTY/TDD deben llamar al 711). Sin embargo, tenga en cuenta que los fines de semana y festivos del 15 de febrero al 30 de septiembre la llamada puede ser enviada al correo de voz.

This booklet is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings. If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it to take effect and you will be ultimately held responsible for those premiums. Please contact AmeriHealth HMO, Inc. at 1-800-898-3492 if you need information in another language other than English or in another format. TTY/TDD: 711.

SilverSneakers is a registered mark of Healthways, Inc.


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Top 100 drugs covered

KEYTiers = T1, T2, T3, T4, T5

T1 = $4 copay (Preferred Generic)

T2 = $9 copay (Non-Preferred Generic)

T3 = $45 copay (Preferred Brand)

T4 = $95 copay (Non-Preferred Brand)

T5 = 25% coinsurance (Specialty Tier)

Italics = generic drugsCAPS = brand-name drugs

Top 100 utilized drugs for AmeriHealth 65® Preferred Rx (HMO)Below is a list of the top 100 utilized prescription drugs covered by AmeriHealth New Jersey.

This is not a complete list of the drugs covered by our plan, and some of these drugs may be subject to limitations or require prior authorization. For a complete listing that includes prior authorization, step therapy, and quantity limitations, please call 1-800-898-3492 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m. or search the online Drug List at amerihealthmedicare.com. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

Y0041 _ H3156 _ AH _ 15 _ 18218 Accepted 6/13/2014

Drug name TierAcetaminophen/Codeine 2Acetaminophen/Hydrocodone

2

ADVAIR DISKUS 3Alendronate 2Allopurinol 2Alprazolam 2Amlodipine 2Amlodipine/Benazepril 1Amoxicillin 2Amoxicillin/Potassium/Clavulanate

2

Atenolol 2Atorvastatin 1Azithromycin 2Carvedilol 2Cephalexin 2Ciprofloxacin 2Citalopram 2Clonazepam 2Clonidine 2Clopidogrel 2CRESTOR 3Cyclobenzaprine 2Diazepam 2Digoxin 2

Drug name TierDiltiazem 2Diltiazem ER 2Donepezil 2Duloxetine 2Enalapril 1Escitalopram 2Famotidine 2Fenofibrate 2Finasteride 2Fluoxetine 2Fluticasone 2Furosemide 2Gabapentin 2Glimepiride 1Glipizide 1Hydralazine 2Hydrochlorothiazide 2Ibuprofen 2Isosorbide Mononitrate ER 2JANUVIA 3Klor-Con ER 2Lansoprazole 2LANTUS 3Latanoprost 2Levofloxacin 2

AmeriHealth HMO, Inc. is an HMO plan with a Medicare contract. Enrollment in AmeriHealth HMO, Inc. depends on contract renewal. The top 100 utilized drugs is based on data from 2014. The top 100 utilized drug list was provided by FutureScripts® Secure on 08/25/2014.This is not a complete list of drugs covered by our plan. For a complete listing, please call 1-800-898-3492 (TTY/TDD: 711) or visit amerihealthmedicare.com.The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. Benefits underwritten or administered by AmeriHealth HMO, Inc.

2014-1544 (10/14)

Drug name TierLevothyroxine 2Lisinopril 1Lisinopril/Hydrochlorothiazide

1

Lorazepam 2Losartan/Hydrochlorothiazide

1

Losartan Potassium 1Lovastatin 1Meloxicam 2Metformin 1Metformin ER 1Methylprednisolone 2Metoprolol/Hydrochlorothiazide

2

Metoprolol Succinate ER 2Metoprolol Tartrate 2Mirtazapine 2Montelukast 2NAMENDA 3Naproxen 2Nifedipine ER 2NOVOLOG 3Omeprazole 2Oxycodone 2Oxycodone/Acetaminophen

2

Pantoprazole 2Paroxetine 2

Drug name TierPravastatin 1Prednisolone Acetate 2Prednisone 2PROAIR HFA 3Quetiapine 2Ramipril 1Ranitidine 2Risperidone 2Sertraline 2Simvastatin 1Spironolactone 2SPIRIVA 3Sulfamethoxazole/Trimethoprim

2

SYNTHROID 4Tamsulosin 2Temazepam 2Tramadol 2Trazodone 2Triamterene/Hydrochlorothiazide

2

Valsartan/Hydrochlorothiazide

1

Venlafaxine ER 2VENTOLIN HFA 3Verapamil ER 2Warfarin 2ZETIA 3Zolpidem 2

KEYTiers = T1, T2, T3, T4, T5

T1 = $4 copay (Preferred Generic)

T2 = $9 copay (Non-Preferred Generic)

T3 = $45 copay (Preferred Brand)

T4 = $95 copay (Non-Preferred Brand)

T5 = 25% coinsurance (Specialty Tier)

Italics = generic drugsCAPS = brand-name drugs

Ready to enroll?

Y0041_H3156_AH_15_18675 Approved (6/13/2014) 4644(10/14)PROINS

OnlineTo find a PCP, you can visit our website amerihealthmedicare.com and use our Provider Directory.

By phone

If you feel more comfortable speaking with someone on the phone, please call toll-free 1-800-898-3492 (TTY/TDD: 711). One of our friendly, local representatives will be available to assist you seven days a week, 8 a.m. to 8 p.m. Be sure to tell the representative which plan you want – AmeriHealth 65 HMO – so he or she uses the correct Provider Directory. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

Once you’ve selected a PCP, write the PCP’s name and code number on your enrollment form.

Have questions about the different provider networks?

Need assistance selecting a PCP?

Want an AmeriHealth 65 HMO Provider Directory mailed to your home?

Contact us today. We’re here to help!


AmeriHealth HMO, Inc. is an HMO plan with a Medicare contract. Enrollment in AmeriHealth HMO, Inc. depends on contract renewal. Members may enroll in the plan only during specific times of the year. Contact AmeriHealth 65 HMO for more information. You must receive all routine care from plan providers. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

Before enrollingin AmeriHealth 65® HMO, you must first select a primary care physician (PCP).

Here’s how:

Y0041_H3156_AH_15_18324 Approved (6/13/2014) 4644(10/14)EI

Ready to sign up for an

AmeriHealth 65® HMO plan?Here are easy step-by-step instructions for filling out the enrollment form.

Once your enrollment is accepted by the Centers for Medicare & Medicaid Services, we will send your new member materials, including your AmeriHealth 65 Preferred HMO ID card.



Personal InformationPlease check [✔] the box in front of the AmeriHealth 65 Preferred HMO plan you want to enroll in. Then provide the personal information requested.

Medicare Insurance InformationYou will need your Medicare card to complete this section.

Your Plan PremiumPlease check [✔] the box in front of the payment option you prefer. If you are interested in a payment option other than what is shown, please contact us at the number provided.

Important QuestionsPlease answer all five questions in this section.

Choose Your ProviderTo complete Section E, you need to select a primary care physician (PCP) from our provider network.

Determining Your Enrollment PeriodPlease check [✔] the box in front of the statements that apply to you.

Your Signature Please read the information provided, then sign and date your enrollment form. If you are an authorized representative, please provide the information requested.

SECTION

ASECTION

BSECTION

CSECTION

DSECTION

ESECTION

FSECTION

GCALL USPlease call toll-free 1-800-898-3492 (TTY/TDD: 711).

GO ONLINE Go to amerihealthmedicare.com to review plan information and enroll online.

Have questions or looking for faster enrollment?

After You Enroll.After you enroll, use this checklist to keep track of your new plan. You will hear

from us within approximately 30 days of your acceptance into the plan.

Material Name Description Delivery

Plan confirmation/ acceptance letter

Enrollment verification call or letter

Your bill

Member ID card

New member welcome kit

Health needs assessment

Doctor visit

We will send you a letter once the Centers for Medicare & Medicaid Services approve your enrollment.

Medicare requires that we call you after we get your enrollment application. We will ask you a few questions to make sure you understand your plan’s features. Your answers will not affect your enrollment. Your sales agent will not be on the call. If we can’t reach you by phone, we’ll mail you an enrollment verification letter.

We generate premium bills each month. If you have a plan with a premium and you signed up for your plan early in the month, you may get your first bill before your plan’s start date. If you signed up later in the month, your first bill may include two months of premiums. (Our billing cycle factors in one month’s premium in advance.) To join one of our plans, you’ll need to continue paying your Medicare Part A and/or Part B premiums (if not otherwise paid for under Medicaid or another third party). This is in addition to your AmeriHealth New Jersey Medicare plan coverage.

Use your AmeriHealth New Jersey member ID card (not your Medicare card) every time you visit the doctor, hospital, or pharmacy (if you have prescription coverage).

This kit contains your Evidence of Coverage (EOC) — a complete description of your Medicare plan coverage and your rights as a member. It also contains a provider directory, a drug formulary (if applicable), and other important forms.

You may receive a health risk assessment survey that helps us learn more about your health care needs. The information provided will not affect your enrollment in the plan or your premium.

Be sure to take advantage of your annual wellness visit, which is covered by Medicare without a copay or coinsurance. It’s a great opportunity for you and your doctor to review your medical history, identify risk factors to your health, and discuss a plan to prevent illness and improve your health in the future.

or

AmeriHealth HMO, Inc. is an HMO plan with a Medicare contract. Enrollment in AmeriHealth HMO, Inc. depends on contract renewal.Benefits underwritten or administered by AmeriHealth HMO, Inc.

or

Y0041_H3156_AH_15_19999 Approved (7/28/2014)

Summary of benefits

2015 Summary of BenefitsEffective January 1, 2015, through December 31, 2015

Y0041_H3156_AH_15_18888 Accepted 09/01/2014H3156

1

Section I: Introduction to Summary of Benefits

You have choices about how to get your Medicare benefits• One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original

Medicare is run directly by the Federal government.

• Another choice is to get your Medicare benefits by joining a Medicare health plan (such as AmeriHealth 65 Preferred Medical Only (HMO) and AmeriHealth 65 Preferred Rx (HMO)).

Tips for comparing your Medicare choicesThis Summary of Benefits booklet gives you a summary of what AmeriHealth 65 Preferred Medical Only (HMO) and AmeriHealth 65 Preferred Rx (HMO) cover and what you pay.

• If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.

• If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Sections in this booklet• Things to Know About AmeriHealth 65 Preferred Medical Only (HMO) and AmeriHealth 65 Preferred

Rx (HMO)• Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

• Covered Medical and Hospital Benefits

• Prescription Drug Benefits (for AmeriHealth 65 Preferred Rx (HMO))This document is available in other formats such as Braille and large print.This document may be available in a non-English language. For additional information, call us at 1-800-898-3492. (TTY/TDD: 711).

Este documento está disponible en otros formatos, entre ellos, Braille y letras grandes. Este documento puede estar disponible en otros idiomas que no sean el inglés. Para información adicional, llámenos al 1-800-898-3492. (TTY/TDD: 711).

Things to Know About AmeriHealth 65 Preferred Medical Only (HMO) and AmeriHealth 65 Preferred Rx (HMO)Hours of Operation• From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time.

• From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time.

AmeriHealth 65 Preferred Medical Only (HMO) and AmeriHealth 65 Preferred Rx (HMO) Phone Numbers and Website

• If you are a member of one of these plans, call toll-free 1-866-569-5190 (TTY/TDD: 711).• If you are not a member of one of these plans, call toll-free 1-800-898-3492 (TTY/TDD: 711).• Our website: http://www.amerihealthmedicare.com

2

Section I: Introduction to Summary of BenefitsWho can join?To join AmeriHealth 65 Preferred Medical Only (HMO) or AmeriHealth 65 Preferred Rx (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

For AmeriHealth 65 Preferred Medical Only (HMO) and AmeriHealth 65 Preferred Rx (HMO), our ser-vice area includes the following counties in New Jersey: Atlantic, Bergen, Burlington, Camden, Cape May, Cum-berland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex, Union and Warren.

Which doctors, hospitals, and pharmacies can I use?AmeriHealth 65 Preferred Medical Only (HMO) and AmeriHealth 65 Preferred Rx (HMO) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You must generally use network pharmacies to fill your prescriptions for covered Part D drugs (for AmeriHealth 65 Preferred Rx (HMO)).You can see our plans’ provider and pharmacy directory at our website (http://www.amerihealthmedicare.com).

Or, call us and we will send you a copy of the provider and pharmacy directory.

What do we cover?Like all Medicare health plans, we cover everything that Original Medicare covers - and more.

• Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plans than you would in Original Medicare. For others, you may pay less.

• Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet.

AmeriHealth 65 Preferred Medical Only (HMO) covers Part B drugs including chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs.

AmeriHealth 65 Preferred Rx (HMO) covers Part D drugs. In addition, we cover Part B drugs such as chemo-therapy and some drugs administered by your provider.

• You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, http://www.amerihealthmedicare.com.

• Or, call us and we will send you a copy of the formulary

How will I determine my drug costs?

AmeriHealth 65 Preferred Rx (HMO) groups each medication into one of five “tiers.” You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

If you have any questions about these plans’ benefits or costs, please contact AmeriHealth 65 Preferred HMO for details.

3


4


4


5

Section II: Summary of Benefits

Benefit CategoryAmeriHealth 65 Preferred Medical Only (HMO)

AmeriHealth 65 Preferred Rx (HMO)

MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICESHow much is the monthly premium?

Please refer to the Premium/Cost-Sharing Table to find out the premium/cost-sharing in your area.

Please refer to the Premium/Cost-Sharing Table to find out the premium/cost-sharing in your area.

How much is the deductible?

This plan does not have a deductible. $320 per year for Part D prescription drugs.

Is there any limit on how much I will pay for my covered services?

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.

Your yearly limit(s) in this plan:

• $6,700 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums.

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.

Your yearly limit(s) in this plan:

• $6,700 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Is there a limit on how much the plan will pay?

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.


6




COVERED MEDICAL AND HOSPITAL BENEFITSNOTE:

• SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION.

• SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR.

NOTE:

• SERVICES WITH A 1

MAY REQUIRE PRIOR AUTHORIZATION.

• SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR.

OUTPATIENT CARE AND SERVICES

Acupuncture and Other Alternative Therapies

Not covered Not covered

Ambulance1 $200 copay

Copayment not waived if admitted.

$200 copay

Copayment not waived if admitted.

Chiropractic Care2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay

Dental Services2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):

$0-50 copay, depending on the service

Preventive dental services:

• Cleaning (for up to 1 every six months): You pay nothing

• Oral exam (for up to 1 every six months): You pay nothing

Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):

$0-50 copay, depending on the service

Preventive dental services:

• Cleaning (for up to 1 every six months): You pay nothing

• Oral exam (for up to 1 every six months): You pay nothing

Diabetes Supplies and Services1

Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: You pay nothing

Therapeutic shoes or inserts: You pay nothing

Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: You pay nothing

Therapeutic shoes or inserts: You pay nothing

7




Diagnostic Tests, Lab and Radiology Services, and X-Rays1,2

Diagnostic radiology services (such as MRIs, CT scans): $50-150 copay, depending on the service

Diagnostic tests and procedures: You pay nothing

Lab services: You pay nothing

Outpatient X-rays: $50 copay

Therapeutic radiology services (such as radiation treatment for cancer): $60 copay

Diagnostic radiology services (such as MRIs, CT scans): $50-150 copay, depending on the service

Diagnostic tests and procedures: You pay nothing

Lab services: You pay nothing

Outpatient X-rays: $50 copay

Therapeutic radiology services (such as radiation treatment for cancer): $60 copay

Doctor’s Office Visits2 Primary care physician visit: $20 copay

Specialist visit: $50 copay

Primary care physician visit: $20 copay

Specialist visit: $50 copay

Durable Medical Equipment (wheelchairs, oxygen, etc.)1

20% of the cost 20% of the cost

Emergency Care $65 copay

Worldwide coverage, copayment not waived if admitted.

$65 copay

Worldwide coverage, copayment not waived if admitted.

Foot Care (podiatry services)2

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 copay

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 copay

Hearing Services2 Exam to diagnose and treat hearing and balance issues: $50 copay

Routine hearing exam (for up to 1 every three years): $50 copay

Hearing aid fitting/evaluation (for up to 2 every three years): $50 copay

Hearing aid: You pay nothing

Our plan pays up to $500 every three years for hearing aids.

Exam to diagnose and treat hearing and balance issues: $50 copay

Routine hearing exam (for up to 1 every three years): $50 copay

Hearing aid fitting/evaluation (for up to 2 every three years): $50 copay

Hearing aid: You pay nothing

Our plan pays up to $500 every three years for hearing aids.

8




Home Health Care1 You pay nothing You pay nothing

Mental Health Care1 Inpatient visit:

Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

• $200 copay per day for days 1 through 7

• You pay nothing per day for days 8 through 90

Outpatient group therapy visit:

$25 copay

Outpatient individual therapy visit:

$25 copay

Inpatient out-of-pocket per day copayments listed are per stay

Inpatient visit:

Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.



Outpatient group therapy visit:

$25 copay

Outpatient individual therapy visit:

$25 copay

Inpatient out-of-pocket per day copayments listed are per stay

Outpatient Rehabilitation2

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $25 copay

Occupational therapy visit: $25 copay

Physical therapy and speech and language therapy visit: $25 copay

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $25 copay

Occupational therapy visit: $25 copay

Physical therapy and speech and language therapy visit: $25 copay

9




Outpatient Substance Abuse

Group therapy visit: $25 copay

Individual therapy visit: $25 copay

Group therapy visit: $25 copay

Individual therapy visit: $25 copay

Outpatient Surgery1 Ambulatory surgical center: $100 copay

Outpatient hospital: $0-350 copay, depending on the service

Ambulatory surgical center: $100 copay

Outpatient hospital: $0-350 copay, depending on the service

Over-the-Counter Items Not Covered Not Covered

Prosthetic Devices (braces, artificial limbs, etc.)1

Prosthetic devices: 20% of the cost

Related medical supplies: 20% of the cost

Prosthetic devices: 20% of the cost

Related medical supplies: 20% of the cost

Renal Dialysis 20% of the cost 20% of the cost

Transportation Not covered Not covered

Urgent Care $20-50 copay, depending on the service $20-50 copay, depending on the service

10




Vision Services2 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0- 50 copay, depending on the service

Routine eye exam (for up to 1 every two years): $50 copay

Contact lenses (for up to 1 every two years): You pay nothing

Eyeglass frames (for up to 1 every two years): You pay nothing

Eyeglass lenses (for up to 1 every two years): You pay nothing

Eyeglasses or contact lenses after cataract surgery: You pay nothing

Our plan pays up to $100 every two years for contact lenses, eyeglass lenses, and eyeglass frames.

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-50 copay, depending on the service

Routine eye exam (for up to 1 every two years): $50 copay

Contact lenses (for up to 1 every two years): You pay nothing

Eyeglass frames (for up to 1 every two years): You pay nothing

Eyeglass lenses (for up to 1 every two years): You pay nothing

Eyeglasses or contact lenses after cataract surgery: You pay nothing

Our plan pays up to $100 every two years for contact lenses, eyeglass lenses, and eyeglass frames.

Preventive Care You pay nothing

Our plan covers many preventive services, including:

• Abdominal aortic aneurysm screening

• Alcohol misuse counseling

• Bone mass measurement

• Breast cancer screening (mammogram)

• Cardiovascular disease (behavioral therapy)

You pay nothing

Our plan covers many preventive services, including:

• Abdominal aortic aneurysm screening

• Alcohol misuse counseling

• Bone mass measurement

• Breast cancer screening (mammogram)

• Cardiovascular disease (behavioral therapy)

11




Preventive Care • Cardiovascular screenings

• Cervical and vaginal cancer screening

• Colonoscopy

• Colorectal cancer screenings

• Depression screening

• Diabetes screenings

• Fecal occult blood test

• Flexible sigmoidoscopy

• HIV screening

• Medical nutrition therapy services

• Obesity screening and counseling

• Prostate cancer screenings (PSA)

• Sexually transmitted infections screening and counseling

• Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

• Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

• “Welcome to Medicare” preventive visit (one-time)

• Yearly “Wellness” visit

Any additional preventive services approved by Medicare during the contract year will be covered.

• Cardiovascular screenings

• Cervical and vaginal cancer screening

• Colonoscopy

• Colorectal cancer screenings

• Depression screening

• Diabetes screenings

• Fecal occult blood test

• Flexible sigmoidoscopy

• HIV screening

• Medical nutrition therapy services

• Obesity screening and counseling

• Prostate cancer screenings (PSA)

• Sexually transmitted infections screening and counseling

• Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

• Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

• “Welcome to Medicare” preventive visit (one-time)

• Yearly “Wellness” visit

Any additional preventive services approved by Medicare during the contract year will be covered.

Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

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INPATIENT CARE

Inpatient Hospital Care1Our plan covers an unlimited number of days for an inpatient hospital stay.



• You pay nothing per day for days 91 and beyond

Out-of-pocket copayments listed are per stay

Our plan covers an unlimited number of days for an inpatient hospital stay.



• You pay nothing per day for days 91 and beyond

Out-of-pocket copayments listed are per stay

Inpatient Mental Health Care

For inpatient mental health care, see the “Mental Health Care” section of this booklet.

For inpatient mental health care, see the “Mental Health Care” section of this booklet.

Skilled Nursing Facility (SNF)1

Our plan covers up to 100 days in a SNF.• $0 copay per day for days 1

through 20


Our plan covers up to 100 days in a SNF.• $0 copay per day for days 1

through 20


13




PRESCRIPTION DRUG BENEFITS

How much do I pay? For Part B drugs such as chemotherapy drugs1: 20% of the cost

Other Part B drugs1: 20% of the cost

Our plan does not cover Part D prescription drugs.

For Part B drugs such as chemotherapy drugs1: 20% of the cost

Other Part B drugs1: 20% of the cost

Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $2,960.

Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies and mail-order pharmacies.

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Standard Retail Cost-Sharing

Tier One-

month

supply

Two-

month

supply

Three-

month

supply

Tier 1

(Preferred Generic) $4

copay

$8

copay

$12

copay

Tier 2

(Non-Preferred Generic) $9

copay

$18

copay

$27

copay

Tier 3

(Preferred Brand) $45

copay

$90

copay

$135

copay

Tier 4

(Non-Preferred Brand) $95

copay

$190

copay

$285

copay

Tier 5

(Specialty Tier) 25% of

the cost

25% of

the cost

25% of

the cost

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Standard Mail Order Cost-Sharing

Tier One-

month

supply

Two-

month

supply

Three-

month

supply

Tier 1

(Preferred Generic) $4

copay

$8

copay

$8

copay

Tier 2

(Non-Preferred Generic)

$9

copay

$18

copay

$18

copay

Tier 3

(Preferred Brand) $45

copay

$90

copay

$90

copay

Tier 4

(Non-Preferred Brand) $95

copay

$190

copay

$190

copay

Tier 5

(Specialty Tier) 25% of

the cost

25% of

the cost

25% of

the cost

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

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Coverage Gap Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2,960.

After you enter the coverage gap, you pay 45% of the plan’s cost for covered brand name drugs and 65% of the plan’s cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of:

• 5% of the cost, or

• $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs

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If You Live In...

And You Have...

AmeriHealth 65 PreferredMedical Only (HMO)


Your monthly premium is...

Atlantic County

$120 per month. In addition, you must keep paying your Medicare Part B premium.


Burlington, Camden, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Ocean, Salem, Somerset and Union



Bergen, Cape May, Monmouth, Morris, Passaic, Sussex and Warren

$55 per month. Inaddition, you must keep paying your Medicare Part B premium.


Premium/Cost-Sharing Table If you have any questions about this plan, please call 800-898-3492 (TTY/TDD 711).

PO Box 7820 Philadelphia, PA 19101-7820

www.amerihealthmedicare.com

For more information . . .For updated information regarding plan providers, visit our website at www.amerihealthmedicare.com, or call our Member Help Team at

1-866-569-5190TTY/TDD

711 Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

If you are not yet a member and have questions, please call 1-800-898-3492 or TTY/TDD 711, seven days a week, 8 a.m. to 8 p.m.

AH6413 (10/14)



2015 · For 2015, AmeriHealth 65 Preferred HMO received the following Overall Star Rating from...

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