Page 25 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

$30/$50 $2 500/20%/$100 ER
IN-NETWORK
$2 500/$5 000
$20/$50 $2 000
30%
IN-NETWORK
$2 000/$4 000
000
$6 000/$12 000
000
$4 000/$8 000
000
$30 copay
$20 copay
$50 copay
$50 copay
$100 copay2
$100 copay2
$75 copay
$75 copay
20% coinsurance after deductible
30%
coinsurance after deductible
$50 copay
$50 copay
20% coinsurance after deductible
$50 copay
$75 copay
no no charge no no deductible
no no charge no no deductible
50%
coinsurance after deductible
50%
coinsurance after deductible
20% coinsurance after deductible
30%
coinsurance after deductible
$50 copay
$50 copay
2021 Large Group Plans 23
Please see footnotes on page 45