Page 14 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

AMERIHEALTH ADVANTAGE EPO5
MEDICAL BENEFITS
$30/$60 $2,500/30%
TIER 2
12
Deductible — individual/family
Inpatient Hospital Services (including maternity)11
Outpatient Surgery11
TIER 1
$30 copay, after deductible
30% coinsurance, after deductible
$2,500/$5,0006
Maximum Out-of-Pocket — individual/family
$6,850/$13,7007
Primary Care Visits
$50 copay, after deductible
Specialist Visits
$60 copay, after deductible
$75 copay, after deductible
Emergency Room
$100 copay, after deductible2
Urgent Care Services
$75 copay, after deductible
50% coinsurance, after deductible
Rehabilitation Services3
Chiropractic Care3
$60 copay, after deductible
X-rays and Diagnostic Imaging
50% coinsurance, after deductible
Imaging CT/PT Scans, MRI's11
Laboratory12
50% coinsurance, after deductible
Durable Medical Equipment
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
30% coinsurance, after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
$60 copay, after deductible