Page 25 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

$30/$50 $250 $500/DAY
IN-NETWORK
$250/$500
$30 copay
$500 copay/day, after deductible; (max of 5 days $2,500)9
$30/$50 $500/DAY
IN-NETWORK
$20/$40 $250/DAY
IN-NETWORK
$0/$0
$0/$0
$3,500/$7,000
$3,000/$6,000
$2,500/$5,000
$30 copay
$20 copay
$50 copay
$50 copay
$40 copay
$100 copay2
$100 copay2
$100 copay2
$75 copay
$75 copay
$75 copay
$500 copay/day; (max of 5 days $2,500)9
$250 copay/day; (max of 5 days $1,250)9
$300 copay, after deductible
$300 copay
$200 copay
$50 copay
10% coinsurance, after deductible
$50 copay
no charge
$40 copay
no charge
no charge, no deductible
no charge
no charge
50% coinsurance, after deductible
50% coinsurance
50% coinsurance
$500 copay/day, after deductible; (max of 5 days $2,500)9
$50 copay
$500 copay/day; (max of 5 days $2,500)9
$50 copay
$250 copay/day; (max of 5 days $1,250)9
$40 copay
Please see footnotes on page 43
2021 Large Group Plans 23