Page 24 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

EPO
MEDICAL BENEFITS
$50/$75 $2 500/50%
IN-NETWORK
$2 500/$5 000
NEW PLAN
$40/$60 $2 500/40%
IN-NETWORK
$2 500/$5 000
Deductible — individual/family
Maximum Out-of-Pocket — individual/family
$7 350/$14 700
$6 500/$13 000
Primary Care Visits
$50 copay
$40 copay
Specialist Visits
$75 copay
$60 copay
Emergency Room
$100 copay2
$100 copay2
Urgent Care Services
$75 copay
$75 copay
Inpatient Hospital Services
(including maternity)11
Outpatient Surgery11
50%
coinsurance after deductible
40%
coinsurance after deductible
Rehabilitation Services3
$50 copay
$60 copay
Chiropractic Care3
X-rays and Diagnostic Imaging
50%
coinsurance after deductible
40%
coinsurance after deductible
Imaging
CT/PT Scans MRI's11
Laboratory12
no no charge no no deductible
no no charge no no deductible
Durable Medical Equipment
50%
coinsurance after deductible
50%
coinsurance after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
50%
coinsurance after deductible
40%
coinsurance after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder $50 copay
$60 copay
22