Page 20 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

AMERIHEALTH HOSPITAL ADVANTAGE EPO8
MEDICAL BENEFITS
TIER 1
HSA $2,500/30% $7/50%/$125 RX4
18
Inpatient Hospital Services (including maternity)11
Outpatient Surgery11
30% coinsurance, after deductible
TIER 2
Deductible — individual/family
$2,50010 /$5,0006
Maximum Out-of-Pocket — individual/family
$6,900/$13,8001,7
Primary Care Visits
$50 copay, after deductible
Specialist Visits
$75 copay, after deductible
Emergency Room
30% coinsurance, after deductible
50% coinsurance, after deductible
Urgent Care Services
$100 copay, after deductible
50% coinsurance, after deductible
Rehabilitation Services3
Chiropractic Care3
$60 copay, after deductible
X-rays and Diagnostic Imaging
50% coinsurance, after deductible
Imaging CT/PT Scans, MRI's11
Laboratory12
50% coinsurance, after deductible
Durable Medical Equipment
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
30% coinsurance, after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
$60 copay, after deductible