Page 20 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

AMERIHEALTH ADVANTAGE EPO5
MEDICAL BENEFITS
TIER 1
$15/$25 $1 $1 500 $100/DAY
TIER 2 Deductible — individual/family
$1 500/$3 0006
Maximum Out-of-Pocket — individual/family
$5 000/$10 0007
Primary Care Visits
$15 copay
$30 copay
Specialist Visits
$25 copay
$100 copay2
$75 copay
$50 copay
Emergency Room
$100 copay
after deductible2
Urgent Care Services
Inpatient Hospital Services
(including maternity)11
$100 copay/per day maximum of 5
5
days ($500)9
$300 copay/per day maximum of 5
5
days ($1 500) after deductible9
Outpatient Surgery11
$50 copay
$100 copay
after deductible Rehabilitation Services3
Chiropractic Care3
$25 copay
X-rays and Diagnostic Imaging
$50 copay
Imaging
CT/PT Scans MRI's11
$100 copay
Laboratory12
no no charge no no deductible Durable Medical Equipment
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
50% coinsurance after deductible $100 copay/per day maximum of 5
5
days ($500)9
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder $25 copay
18