Page 19 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

$15/$30 $1,000 $100/DAY
TIER 1
TIER 2
$1,000/$2,0006
$4,000/$8,0007
$15 copay
$50 copay
$30 copay
$75 copay
$100 copay2
$75 copay
$100 copay/per day; maximum of 5 days ($500)9
$300 copay/per day; maximum of 5 days ($1,500)9
$50 copay
$100 copay
$30 copay
$50 copay
$100 copay
no charge, no deductible
50% coinsurance, after deductible
$100 copay/per day; maximum of 5 days ($500)9
$30 copay
Please see footnotes on page 43
2021 Large Group Plans 17