Page 16 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance
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AMERIHEALTH ADVANTAGE EPO5
MEDICAL BENEFITS
TIER 1
$30/$60 $2 500/30%
TIER 2 Deductible — individual/family
$2 500/$5 0006
Maximum Out-of-Pocket — individual/family
$6 850/$13 7007
Primary Care Visits
$30 copay after deductible
$50 copay after deductible
Specialist Visits
$60 copay after deductible
$75 copay after deductible
Emergency Room
$100 copay after deductible2
Urgent Care Services
Outpatient Surgery11
Imaging CT/PT Scans MRI's11
30%
coinsurance after deductible
$75 copay after deductible
50% coinsurance after deductible
Inpatient Hospital Services
(including maternity)11
50% coinsurance after deductible
Rehabilitation Services3
Chiropractic Care3
$60 copay after deductible
X-rays and Diagnostic Imaging Laboratory12
50% coinsurance after deductible
Durable Medical Equipment
50% coinsurance after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder 30%
coinsurance after deductible
$60 copay after deductible
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