Page 35 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

IN-NETWORK
$2,00010 /$4,000
10% coinsurance, after deductible
HSA $2,000/10% $7/$35/$50 RX4
OUT-OF-NETWORK
IN-NETWORK
no charge, after deductible
HSA $1,500/0% $10/$40/$60 RX4
OUT-OF-NETWORK
$5,00010 /$10,000
$1,50010 /$3,000
$3,00010 /$6,000
$5,000/$10,0001
$10,000/$20,000
$1,650/$3,300
$15,000/$30,000
10% coinsurance, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
10% coinsurance, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
10% coinsurance, after deductible
Covered at in-network level
40% coinsurance, after deductible
no charge, after deductible
Covered at in-network level
40% coinsurance, after deductible
40% coinsurance, after deductible
40% coinsurance, after deductible
10% coinsurance, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
10% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
50% coinsurance, after deductible
10% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
10% coinsurance, after deductible
40% coinsurance, after deductible
no charge, after deductible
40% coinsurance, after deductible
Please see footnotes on page 43
2021 Large Group Plans 33