Page 19 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

TIER 1
HSA $1 500/10% $7/50%/$125 RX4
TIER 2 $1 50010 /$3 0006
$3 000/$6 0007
$15 copay
after deductible
$30 copay
after deductible
$30 copay
after deductible
10% coinsurance after deductible
$60 copay
after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
$30 copay
after deductible
10% coinsurance after deductible
no charge after deductible
50% coinsurance after deductible
10% coinsurance after deductible
$30 copay
after deductible
2021 Large Group Plans 17
Please see footnotes on page 45