Page 21 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance
P. 21
TIER 1
$15/$30 $1 $1 000 $100/DAY
TIER 2 $1 000/$2 0006
$4 000/$8 0007
$15 copay
$50 copay
$30 copay
$100 copay2
$75 copay
$75 copay
$100 copay/per day maximum of 5
5
days ($500)9
$300 copay/per day maximum of 5
5
days ($1 500)9
$50 copay
$100 copay
$30 copay
$50 copay
$100 copay
no no charge no no deductible 50% coinsurance after deductible $100 copay/per day maximum of 5
5
days ($500)9
$30 copay
2021 Large Group Plans 19
Please see footnotes on page 45
