Page 17 - Amerihealth New Jersey - Small Group - 2021 Benefits at a Glance

Choose your network
MEDICAL BENEFITS
Outpatient Surgery
Ambulatory Surgical
A NEW PLAN
BENEFITS
$20 / $40
Local Value18
Choose your network
Regional Preferred with NY19
MT I I I I E E E E E E E E E E R R D I I I I 1 C A L B E E E E E N E E E E E T T T F I I I I I I I I E E E E E T T T R R S
2 20% coinsurance after deductible
NEW PLAN
GOLD BENEFITS
Select EPO GOLD 13
meriHealth Advantage
Select EPO AmeriHealth Hospital Advantage14 $30 / $50
Local Value5
50% coinsurance after deductible
Select EPO HSA 0% 0% / 0% 0% Local Value5
NEW Regional Preferred with NY IN-NETWORK
Individual/family
TIER 1 $1 500 / $3 00015
TIER 2 Deductible
Individual/family
Deductible
15
$1 500 / / $3 000 $1 5008 / $3 000 After Deductible
Member pays
After deductible
20% 50% Member pays
20% 50% 0% Maximum Out-of-pocket
Individual/family
Maximum out-of-pocket
$7 000 000 / / $14 00016
Individual/family
$6 000 000 / $12 00016
$5 000 000 / $10 000 000 Primary Care Visits
Specialist Visits
10 $ 2 P 0 0 r r r i c mo p a a a a a a r r r y y y y C a a a r r r $S4p0ecocpiaylist Visits$75 copay
e V$is5i0tscopay10
$30 copay10
No charge after deductible10
$50
copay
No charge after deductible
Urgent Care Services
Emergency Room
Urgent$C75arceopSaeyrvices
1 Emerg$e1n0c0ycoRpoayom
$75 copay
No charge after deductible
$100 copay1 50% coinsurance after deductible
20% coinsurance after deductible
Outpatient Surgery
Ambulatory Surgical
20% coinsurance after deductible
coinsurance Inpatient Hospaitftaelr Sdedruvcictieblse
50% No charge after deductible
Inpatient Hospital Services
Including Maternity
Including Maternity
$500 copay
per day day up to 5 days6
X-rays & Diagnostic Imaging
X-rays & Diagnostic Imaging
20% coinsurance after deductible
$50
copay
No charge after deductible
Imaging
CT/PT Scans MRIs
Imaging
CT/PT Scans MRIs
$100 copay
Laboratory12
Inpatient Treatment
Mental Behavioral Health Substance Use Disorder
LaNboochrartgoe rnyo deductible
12 No charge no deductible
No charge after deductible
Inpatient Treatment
20%MeconitnasulrBaenchea vaifoterradleHdeuactlitbhle Substance Use Disorder
$500 copay
per day day up to 5 5 days6
No charge after deductible
Outpatient treatment
Mental Behavioral Health Substance Use Disorder
Chiropractic Care2
PRESCRIPTION BENEFITS
Outpatient Treatment
Mental$B4e0hcaovpiaoyralHealth Substance Use Disorder
$50
copay
$50
copay
30 DAY SUPPLY4
No charge after deductible
Rehabilitation Therapy Services3
Rehabilitation Therapy Services3
$40
copay
No charge after deductible
Chiropractic Care2
Durable Medical Equipment
50D%ucroaibnslueraMnced aicftaelrEdeqduicptimblent
4 PR3E0SCDRAIYPTSIOUNPPBLEYNEFITS
50% coinsurance after deductible
No charge after deductible
30 DAY SUPPLY4
Generic Rx
G e e n e e r i c$ 1 R5 x c c o p a y $10 copay
$15 copay
after deductible
Brand Rx
Brand R$4x0 copay
50% coinsurance up to $125 max no deductible
50% coinsurance up to $125 max after deductible
Non-preferred Brand Rx
Non-Pr$e7f5ercorepady Brand Rx
AmeriHealth New Jersey | 2021 Small Group health plans 15