Page 17 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

TIER 1
HSA $2 500/30%
$7/50%/$125 RX4
TIER 2 TIER 1
$30/$45 $2 500/30%
TIER 2 $2 50010 /$5 0006
$2 500/$5 0006
$6 900/$13 8001 7 $6 600 /$13 2007
$30 copay after deductible
$50 copay after deductible
$30 copay $50 copay $60 copay after deductible
$75 copay after deductible
$45 copay $75 copay $100 copay after deductible2
$100 copay2
$75 copay after deductible
$75 copay 30%
coinsurance after deductible
50% coinsurance after deductible
30%
coinsurance after deductible
50% coinsurance after deductible
$60 copay after deductible
$45 copay 50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
no no charge no no deductible
50% coinsurance after deductible
50% coinsurance after deductible
30%
coinsurance after deductible
30%
coinsurance after deductible
$60 copay after deductible
$45 copay 2021 Large Group Plans 15
Please see footnotes on page 45