Page 26 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

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EPO HSA
MEDICAL BENEFITS
Maximum Out-of-Pocket — individual/family
HSA $2,500/50% $25/$50/$75 RX4
IN-NETWORK
NEW PLAN
HSA $2,500/30% $25/$50/$75 RX4
IN-NETWORK
HSA $2,500/20% $25/$50/$75 RX4
IN-NETWORK
Deductible — individual/family
$2,50010 /$5,000
$2,50010 /$5,000
$2,50010 /$5,000
$6,900/$13,8001
$6,900/$13,8001
$5,000/$10,0001
Primary Care Visits
Specialist Visits
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
20% coinsurance, after deductible
30% coinsurance, after deductible
20% coinsurance, after deductible
Emergency Room
30% coinsurance, after deductible
20% coinsurance, after deductible
Urgent Care Services
Inpatient Hospital Services (including maternity)11
Outpatient Surgery11
50% coinsurance, after deductible
30% coinsurance, after deductible
20% coinsurance, after deductible
Rehabilitation Services3
30% coinsurance, after deductible
20% coinsurance, after deductible
Imaging CT/PT Scans, MRI's11
50% coinsurance, after deductible
Chiropractic Care3
X-rays and Diagnostic Imaging
50% coinsurance, after deductible
30% coinsurance, after deductible
20% coinsurance, after deductible
Laboratory12
Durable Medical Equipment
no charge, after deductible
no charge, after deductible
no charge, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
50% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
30% coinsurance, after deductible
20% coinsurance, after deductible
20% coinsurance, after deductible