Page 34 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

PPO HSA
MEDICAL BENEFITS
IN-NETWORK
OUT-OF-NETWORK
32
30% coinsurance, after deductible
HSA $2,500/30% $7/$35/$50 RX4
Deductible — individual/family
$2,50010 /$5,000
$5,00010 /$10,000
Maximum Out-of-Pocket — individual/family
$5,000/$10,0001
$10,000/$20,000
Primary Care Visits
50% coinsurance, after deductible
Specialist Visits
30% coinsurance, after deductible
50% coinsurance, after deductible
Emergency Room
Urgent Care Services
30% coinsurance, after deductible
Covered at in-network level
50% coinsurance, after deductible
Inpatient Hospital Services (including maternity)11
30% coinsurance, after deductible
50% coinsurance, after deductible
Outpatient Surgery11
Rehabilitation Services3
Chiropractic Care3
30% coinsurance, after deductible
50% coinsurance, after deductible
X-rays and Diagnostic Imaging
no charge, after deductible
50% coinsurance, after deductible
Imaging CT/PT Scans, MRI's11
30% coinsurance, after deductible
Laboratory12
no charge, after deductible
50% coinsurance, after deductible
Durable Medical Equipment
50% coinsurance, after deductible
50% coinsurance, after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
30% coinsurance, after deductible
50% coinsurance, after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder
30% coinsurance, after deductible
50% coinsurance, after deductible