Page 18 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

MEDICAL BENEFITS
Inpatient Hospital Services (including maternity)11
TIER 1
$100 copay/per day, maximum of 5 days ($500)9
$15/$25 $1,500 $100/DAY
TIER 2
16
AMERIHEALTH ADVANTAGE EPO5
Deductible — individual/family
Outpatient Surgery11
$15 copay
$50 copay
$1,500/$3,0006
Maximum Out-of-Pocket — individual/family
$5,000/$10,0007
Primary Care Visits
$30 copay
Specialist Visits
$25 copay
$50 copay
Emergency Room
$100 copay2
$100 copay, after deductible2
Urgent Care Services
$75 copay
$300 copay/per day, maximum of 5 days ($1,500), after deductible9
$100 copay, after deductible
Rehabilitation Services3
X-rays and Diagnostic Imaging
$25 copay
Chiropractic Care3
$50 copay
Imaging CT/PT Scans, MRI's11
$100 copay
Laboratory12
no charge, no deductible
Durable Medical Equipment
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
$100 copay/per day, maximum of 5 days ($500)9
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
$25 copay