Page 27 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance
P. 27
NEW PLAN
HSA $30/$50 $2,500/0% $25/$50/$75 RX4
IN-NETWORK
$2,50010 /$5,000
no charge, after deductible
HSA $1,500/50% $7/50%/$125 RX4
IN-NETWORK
$1,50010 /$3,000
50% coinsurance, after deductible
HSA $1,500/30% $7/50%/$125 RX4
IN-NETWORK
$1,50010 /$3,000
30% coinsurance, after deductible
HSA $1,500/30% $10/$40/$60 RX4
IN-NETWORK
HSA $2,500/0% $10/$40/$60 RX4
IN-NETWORK
$1,50010 /$3,000
$2,50010 /$5,000
$6,900/$13,8001
$2,500/$5,000
$3,000/$6,000
$3,000/$6,000
$3,000 / $6,000
$30 copay, after deductible
$50 copay, after deductible
$100 copay after deductible2
50% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
30% coinsurance, after deductible
no charge, after deductible
30% coinsurance, after deductible
30% coinsurance, after deductible
no charge, after deductible
50% coinsurance, after deductible
30%, after deductible
30%, after deductible
no charge, after deductible
$75 copay, after deductible
30% coinsurance, after deductible
no charge, after deductible
no charge, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
30% coinsurance, after deductible
no charge, after deductible
$30 copay, after deductible
no charge, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
30% coinsurance, after deductible
no charge, after deductible
no charge, after deductible
50% coinsurance, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
30% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
50% coinsurance, after deductible
no charge, after deductible
30% coinsurance, after deductible
no charge, after deductible
Please see footnotes on page 43
2021 Large Group Plans 25
