Page 29 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

IN-NETWORK
$1,500/$3,000
$30/$50 $1,500/20%
OUT-OF-NETWORK
40% coinsurance, after deductible
IN-NETWORK
$200 copay
$30/$50 $400/DAY
OUT-OF-NETWORK
$3,000/$6,000
$0/$0
$2,500/$5,000
$2,500/$5,000
$6,000/$12,000
$4,000/$8,000
$12,000/$24,000
$30 copay
40% coinsurance, after deductible
$30 copay
40% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$100 copay2
Covered at in-network level
$100 copay2
Covered at in-network level
$75 copay
40% coinsurance, after deductible
$75 copay
40% coinsurance, after deductible
20% coinsurance, after deductible
$400 copay/day; (max of 5 days $2,000)9
40% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$50 copay
40%, after deductible
$50 copay
40% coinsurance, after deductible
$100 copay
$100 copay
no charge, no deductible
40% coinsurance, after deductible
no charge
40% coinsurance, after deductible
50% coinsurance, after deductible
20% coinsurance, after deductible
50% coinsurance, after deductible
40% coinsurance, after deductible
50% coinsurance
50% coinsurance, after deductible
$400 copay/day; (max of 5 days $2,000)9
40% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
Please see footnotes on page 43
2021 Large Group Plans 27