Page 15 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

TIER 1
HSA $2,500/30% $7/50%/$125 RX4
TIER 2
TIER 1
$30/$45 $2,500/30%
TIER 2
$2,50010 /$5,0006
$2,500/$5,0006
$6,900/$13,8001,7
$6,600 /$13,2007
$30 copay, after deductible
$50 copay, after deductible
$30 copay
$50 copay
$60 copay, after deductible
$100 copay, after deductible2
$75 copay, after deductible
$45 copay
$100 copay2
$75 copay
$75 copay, after deductible
$75 copay
30% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
50% coinsurance, after deductible
$60 copay, after deductible
$45 copay
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
no charge, no deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
$60 copay, after deductible
$45 copay
Please see footnotes on page 43
2021 Large Group Plans 13