Page 24 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

EPO
MEDICAL BENEFITS
$30/$50 $1,500/30%
IN-NETWORK
$20/$40 $1,500/20%
22
Deductible — individual/family
$1,500/$3,000
IN-NETWORK
$1,500/$3,000
Maximum Out-of-Pocket — individual/family
$3,000/$6,000
$3,000/$6,000
Primary Care Visits
$30 copay
$20 copay
Specialist Visits
$50 copay
$40 copay
Emergency Room
$100 copay2
$100 copay2
Urgent Care Services
$75 copay
$75 copay
Inpatient Hospital Services (including maternity)11
Rehabilitation Services3
30% coinsurance, after deductible
20% coinsurance, after deductible
Outpatient Surgery11
$50 copay
$40 copay
Chiropractic Care3
X-rays and Diagnostic Imaging
30% coinsurance, after deductible
$20 copay
Imaging CT/PT Scans, MRI's11
$40 copay
Laboratory12
no charge, no deductible
no charge, no deductible
Durable Medical Equipment
50% coinsurance, after deductible
50% coinsurance, no deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
30% coinsurance, after deductible
20% coinsurance, after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
$50 copay
$40 copay