Page 30 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

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POS PLUS
MEDICAL BENEFITS
IN-NETWORK
$30 copay
NEW PLAN
$30/$50 $2,500/50%
OUT-OF-NETWORK
Deductible — individual/family
$2,500/$5,000
$5,000/$10,000
Maximum Out-of-Pocket — individual/family
$5,000/$10,000
$15,000/$30,000
Primary Care Visits
50% coinsurance, after deductible
Specialist Visits
Emergency Room
Urgent Care Services
$50 copay
$100 copay2
$75 copay
50% coinsurance, after deductible
Covered at in-network level
50% coinsurance, after deductible
Inpatient Hospital Services (including maternity)11
Chiropractic Care3
50% coinsurance, after deductible
50% coinsurance, after deductible
Outpatient Surgery11
Rehabilitation Services3
$50 copay
50% coinsurance, after deductible
X-rays and Diagnostic Imaging
Imaging CT/PT Scans, MRI's11
$50 copay
$100 copay
50% coinsurance, after deductible
Laboratory12
no charge, no deductible
50% coinsurance, after deductible
Durable Medical Equipment
50% coinsurance, after deductible
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
50% coinsurance, after deductible
50% coinsurance, after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
$50 copay
50% coinsurance, after deductible