Page 31 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

IN-NETWORK
$30/$50 $2,000/30%
OUT-OF-NETWORK
$3,000/$6,000
50% coinsurance, after deductible
IN-NETWORK
$30/$50 $1,500/20%
OUT-OF-NETWORK
$3,000/$6,000
40% coinsurance, after deductible
IN-NETWORK
$1,000/$2,000
$20/$40 $1,000/10%
OUT-OF-NETWORK
$2,000/$4,000
$1,500/$3,000
$2,000/$4,000
$4,000/$8,000
$15,000/$30,000
$3,000/$6,000
$6,000/$12,000
$2,500/$5,000
$5,000/$10,000
$30 copay
$50 copay
50% coinsurance, after deductible
50% coinsurance, after deductible
$30 copay
$50 copay
40% coinsurance, after deductible
40% coinsurance, after deductible
$20 copay
$40 copay
30% coinsurance, after deductible
30% coinsurance, after deductible
$100 copay2
$75 copay
Covered at in-network level
50% coinsurance, after deductible
$100 copay2
$75 copay
Covered at in-network level
40% coinsurance, after deductible
$100 copay2
$75 copay
Covered at in-network level
30% coinsurance, after deductible
30% coinsurance, after deductible
20% coinsurance, after deductible
10% coinsurance, after deductible
30% coinsurance, after deductible
$50 copay
50% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$40 copay
30% coinsurance, after deductible
$50 copay
50% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$40 copay
30% coinsurance, after deductible
$100 copay
$100 copay
$80 copay
no charge, no deductible
50% coinsurance, after deductible
no charge, no deductible
40% coinsurance, after deductible
no charge, no deductible
30% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
30% coinsurance, after deductible
50% coinsurance, after deductible
20% coinsurance, after deductible
40% coinsurance, after deductible
10% coinsurance, after deductible
30% coinsurance, after deductible
$50 copay
50% coinsurance, after deductible
$50 copay
40% coinsurance, after deductible
$40 copay
30% coinsurance, after deductible
Please see footnotes on page 43
2021 Large Group Plans 29