Page 33 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

IN-NETWORK
$20/$40 $250/DAY
IN-NETWORK
$20/$40 $0/DAY
OUT-OF-NETWORK
30% coinsurance, after deductible
IN-NETWORK
$10/$20 $0/DAY
$0/$0
OUT-OF-NETWORK
$1,000/$3,000
$1,000/$3,000
OUT-OF-NETWORK
$0/$0
$0/$0
$500/$1,500
$2,500/$5,000
$7,500/$15,000
$2,000/$4,000
$6,000/$12,000
$1,500/$3,000
$4,500/$9,000
$20 copay
$40 copay
30% coinsurance, after deductible
30% coinsurance, after deductible
$20 copay
$40 copay
30% coinsurance, after deductible
$10 copay
$20 copay
20% coinsurance, after deductible
30% coinsurance, after deductible
20% coinsurance, after deductible
$100 copay2
Covered at in-network level
$100 copay2
Covered at in-network level
$100 copay2
Covered at in-network level
$75 copay
30% coinsurance, after deductible
$75 copay
30% coinsurance, after deductible
$75 copay
20% coinsurance, after deductible
$250 copay; (max of 5 days $1,250)9
30% coinsurance, after deductible
no charge
no charge
20% coinsurance, after deductible
$125 copay
$40 copay
30% coinsurance, after deductible
$40 copay
30% coinsurance, after deductible
$20 copay
20% coinsurance, after deductible
$40 copay
30% coinsurance, after deductible
$40 copay
$80 copay
30% coinsurance, after deductible
$20 copay
20% coinsurance, after deductible
$80 copay
$40 copay
no charge
30% coinsurance, after deductible
no charge
30% coinsurance, after deductible
no charge
20% coinsurance, after deductible
50% coinsurance
50% coinsurance, after deductible
50% coinsurance
50% coinsurance, after deductible
50% coinsurance
50% coinsurance, after deductible
$250 copay; (max of 5 days $1,250)9
30% coinsurance, after deductible
no charge
30% coinsurance, after deductible
no charge
20% coinsurance, after deductible
$40 copay
30% coinsurance, after deductible
$40 copay
30% coinsurance, after deductible
$20 copay
20% coinsurance, after deductible
Please see footnotes on page 43
2021 Large Group Plans 31