Page 22 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

EPO
MEDICAL BENEFITS
Maximum Out-of-Pocket — individual/family
$50/$75 $2,500/50%
IN-NETWORK
$2,500/$5,000
$7,350/$14,700
NEW PLAN
IN-NETWORK
20
Deductible — individual/family
Primary Care Visits
$50 copay
$75 copay
$40/$60 $2,500/40%
$2,500/$5,000
$6,500/$13,000
$40 copay
Specialist Visits
$60 copay
Emergency Room
$100 copay2
$100 copay2
Urgent Care Services
$75 copay
Inpatient Hospital Services (including maternity)11
$75 copay
50% coinsurance, after deductible
40% coinsurance, after deductible
Outpatient Surgery11
Rehabilitation Services3
$50 copay
$60 copay
Chiropractic Care3
X-rays and Diagnostic Imaging
Imaging CT/PT Scans, MRI's11
50% coinsurance, after deductible
40% coinsurance, after deductible
Laboratory12
no charge, no deductible
no charge, no deductible
Durable Medical Equipment
50% coinsurance, after deductible
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
50% coinsurance, after deductible
40% coinsurance, after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
$50 copay
$60 copay