Page 16 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance
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MEDICAL BENEFITS
$20/$40 $2,000/20%
TIER 2
14
AMERIHEALTH ADVANTAGE EPO5
Deductible — individual/family
Inpatient Hospital Services (including maternity)11
Outpatient Surgery11
TIER 1
$20 copay
20% coinsurance, after deductible
$2,000/$4,0006
Maximum Out-of-Pocket — individual/family
$5,000/$10,0007
Primary Care Visits
$50 copay
Specialist Visits
$75 copay
Emergency Room
$40 copay
$100 copay2
Urgent Care Services
$75 copay
50% coinsurance, after deductible
Rehabilitation Services3
$40 copay
Chiropractic Care3
X-rays and Diagnostic Imaging
50% coinsurance, after deductible
Imaging CT/PT Scans, MRI's11
Laboratory12
no charge, no deductible
Durable Medical Equipment
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
20% coinsurance, after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
$40 copay
