Page 15 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

TIER 1
NEW PLAN
3-TIER NATL ACCESS EPO HSA $1 500/10% $7/50%/$125 RX
TIER 2 TIER 3 TIER 1
NEW PLAN
3-TIER NATL ACCESS EPO $15/$25
$1 $1 500 $100/day
TIER 2 TIER 3 $1 50010 /$3 000 $2 50010 /$5 000 $1 500/$3 000 $6 000/$12 00014
$2 500/$5 000 $5 000/$10 0001 14
$15 copay after deductible
$30 copay after deductible
$50 copay after deductible
$15 copay $30 copay $50 copay $30 copay after deductible
$60 copay after deductible
$75 copay after deductible
$25
copay $50 copay $75 copay 30% coinsurance after deductible
30% coinsurance after deductible
$100 copay2
$100 copay after deductible2
30% coinsurance after deductible
30% coinsurance after deductible
$75 copay 10% coinsurance after deductible
30% coinsurance after deductible
50% coinsurance after deductible
$100 copay/day maximum of 5
5
days ($500)9
$300 copay/day maximum of 5
5
days ($1 500) after deductible9
$500 copay/day maximum of 5
5
days ($2 500) after deductible9
$50 copay $100 copay after deductible
$150 copay after deductible
$30 copay after deductible
$30 copay after deductible
$25
copay 30% coinsurance after deductible
30% coinsurance after deductible
$50 copay $100 copay no charge after deductible
no charge after deductible
no no charge no no deductible
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
$100 copay/day maximum of 5
5
days ($500)9
$30 copay after deductible
$30 copay after deductible
$25
copay 2021 Large Group Plans 13 Please see footnotes on page 45