Page 17 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

HSA $1,500/10% $7/50%/$125 RX4
TIER 1
TIER 2
$1,50010 /$3,0006
$3,000/$6,0007
$15 copay, after deductible
$30 copay, after deductible
$30 copay, after deductible
$60 copay, after deductible
10% coinsurance, after deductible
10% coinsurance, after deductible
10% coinsurance, after deductible
30% coinsurance, after deductible
$30 copay, after deductible
10% coinsurance, after deductible
no charge, after deductible
50% coinsurance, after deductible
10% coinsurance, after deductible
$30 copay, after deductible
Please see footnotes on page 43
2021 Large Group Plans 15