Page 22 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

AMERIHEALTH HOSPITAL ADVANTAGE EPO8
MEDICAL BENEFITS
TIER 1
HSA $2 500/30% $7/50%/$125 RX4
TIER 2 Deductible — individual/family
$2 50010 /$5 0006
Maximum Out-of-Pocket — individual/family
$6 900/$13 8001 7 Primary Care Visits
$50 copay after deductible
Specialist Visits
$75 copay after deductible
Emergency Room
30% coinsurance after deductible
$100 copay after deductible
50% coinsurance after deductible
Urgent Care Services
Inpatient Hospital Services
(including maternity)11
30% coinsurance after deductible
50% coinsurance after deductible
Outpatient Surgery11
Rehabilitation Services3
$60 copay after deductible
Chiropractic Care3
50% coinsurance after deductible
X-rays and Diagnostic Imaging
Imaging
CT/PT Scans MRI's11
Laboratory12
50% coinsurance after deductible
Durable Medical Equipment
50% coinsurance after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
30% coinsurance after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder $60 copay after deductible
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