Page 18 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance
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AMERIHEALTH ADVANTAGE EPO5
MEDICAL BENEFITS
Deductible — individual/family
TIER 1
$20/$40 $2 000/20%
$2 000/$4 0006
TIER 2 Maximum Out-of-Pocket — individual/family
$5 000/$10 0007
Primary Care Visits
$20 copay
$50 copay
Specialist Visits
Emergency Room
$40 copay
$75 copay
$100 copay2
Urgent Care Services
$75 copay
Inpatient Hospital Services
(including maternity)11
20%
coinsurance after deductible
50% coinsurance after deductible
Outpatient Surgery11
Rehabilitation Services3
Chiropractic Care3
$40 copay
X-rays and Diagnostic Imaging
Imaging
CT/PT Scans MRI's11
50% coinsurance after deductible
Laboratory12
no no charge no no deductible
Durable Medical Equipment
50% coinsurance after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
20%
coinsurance after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder $40 copay
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