Page 26 - Amerihealth New Jersey - Small Group - 2021 Benefits at a Glance

Important health plan information
All plans within this this brochure brochure reflect member cost-sharing The benefits summaries in in in this this brochure brochure represent only a a a a a a partial listing of of benefits of of the the health plans Benefits and exclusions may be be further defined by medical policy These managed care plans may not cover all your your health health care care care expenses Read your your contract carefully to determine which health health care care care services are are are are covered If you you need more information
please contact your broker Medical Footnotes:
1 Emergency room copay waived if admitted 2 Members can utilize 30 visits per per benefit period 3 3 3 Members can utilize 30 30 visits visits combined combined for for physical and and and occupational therapy therapy per per per per benefit benefit period period and and and 30 30 visits visits combined combined for for speech and and and cognitive therapy therapy per per per per benefit benefit period period 4 Prescription mail order benefit is available at 2x applicable cost-sharing for a a a a a a a a a a 90-day supply 5 The Local Value network is not available in Hunterdon County 6 Copay Copay is is required per per day day day up to a a a a a a a a a a maximum of 5 days days per per admission Copay Copay waived if readmitted within 90 days days 7 Copay waived if readmitted within 90 days 8 Individual deductible not applicable in in policies covering 2 or or more people 9 Certain services may require a a a a a a a referral from your primary care physician 10 You are are required to select a a a a a primary care physician 11 $100 Rx deductible per per person 12 Laboratory Corporation of America® Holdings (LabCorp) is is AmeriHealth New Jersey’s exclusive outpatient laboratory provider To find your closest patient patient service center location visit LabCorp LabCorp com 13 AmeriHealth AmeriHealth Advantage Advantage plans are only available to to employers based in in in in in the the the following counties: Atlantic Burlington Camden Cape May Essex Gloucester Hudson Mercer Middlesex Monmouth Ocean Somerset and Union Members can can obtain services within within the the the the listed counties counties at the the the the tier tier tier 1 1 level AmeriHealth AmeriHealth AmeriHealth AmeriHealth Advantage Advantage Advantage members can can also access tier tier tier 2 providers within within the the the AmeriHealth AmeriHealth AmeriHealth New Jersey Local Value or or Regional Preferred with with NY network contingent on
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plan selection AmeriHealth AmeriHealth AmeriHealth Advantage Advantage tier tier tier 1 1 hospitals are subject to change 14 AmeriHealth AmeriHealth Hospital Advantage providers providers providers are are an an an enhancement to your benefits Tier 2 providers providers providers are are AmeriHealth AmeriHealth New Jersey Local Value network providers providers providers 15 Deductible is combined for tier tier 1 1 and tier tier 2 16 Out-of-pocket maximum is combined for tier tier 1 1 and tier tier 2 17 The maximum applies prior to the deductible being met 18 Tier 2 is is the Local Local Value Value network network The Local Local Value Value network network is is not available in Hunterdon County 19 Tier 2 is the Regional Preferred with NY network Dental Footnotes:
1 AmeriHealth New Jersey dental plans are administered by United Concordia Companies Inc 2 This summary is is intended to to to highlight the the benefits benefits available to to to you For a a a a a a a a a a a a complete program description including all benefits benefits limitations and exclusions please refer to to to the the dental contract 3 3 0-18 rate capped at at 3 3 members<19 4 If you you choose to use a a a a a a a a a non-network non-network dentist dentist you you may pay pay the the the the the difference between the the the the the amount amount the the the the the plan pays and the the the the the amount amount charged by the the the the the non-network non-network dentist dentist 5 Pediatric dental dental benefits benefits only cover cover up to to age age age 19 19 Be sure to to purchase a a a a a a a a a a a a a a dental dental care plan that provides benefits benefits for anyone age age age 19 19 and older in your family who needs coverage 6 Pediatric benefits through end of contract year in which member reaches age 19 7 Cosmetic orthodontia covered up to a a a lifetime max of $1 000 per child 8 Implants are not covered covered Under certain circumstances implants may be covered covered for children younger than 19 years of age Vision Footnotes:
1 Administered by Davis Vision 2 An AmeriHealth New Jersey affiliate has a a a a a a a financial interest in in in Visionworks 3 Adult Vision Vision Care plans plans cover members members 19 19 19 and older as as well as as child dependents age 19 19 19 to 26 Vision Vision benefits for members members under 19 19 19 are are included in in the medical plans plans 4 Depending on
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the the the plan the the the group purchases your exam will either be once every calendar year year or contract year year 5 Anything related to this discount is is is handled by QualSight 6 This website is is an out-of-network service 7 In Network Benefits Network Options Footnotes:
1 Coverage provided by Multiplan PHCS National Network AmeriHealth AmeriHealth New New Jersey Jersey members accessing care in in the the AmeriHealth AmeriHealth New New Jersey Jersey service area must use the the Regional Preferred network 2 Data derived from analysis of information
by a a a a a a a a a third-party vendor and is is subject to change 3 The AmeriHealth New New Jersey Jersey service area area includes all New New Jersey Jersey and and and Delaware Delaware counties counties counties and and and nine Pennsylvania counties counties counties in in in in in the Philadelphia Philadelphia area area including: Berks Bucks Chester Delaware Delaware Lancaster Lehigh Montgomery Northampton and and Philadelphia counties 4 The Local Value network is not available in Hunterdon county 24