Page 26 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

EPO
MEDICAL BENEFITS
$30/$50 $1 500/30%
IN-NETWORK
30%
coinsurance after deductible
$20/$40 $1 500/20%
IN-NETWORK
$1 500/$3 000
$20 copay
20%
coinsurance after deductible
Deductible — individual/family
$1 500/$3 000
Maximum Out-of-Pocket — individual/family
$3 000/$6 000
000
$3 000/$6 000
000
Primary Care Visits
$30 copay
Specialist Visits
$50 copay
$40 copay
Emergency Room
$100 copay2
$100 copay2
Urgent Care Services
$75 copay
$75 copay
Inpatient Hospital Services
(including maternity)11
Outpatient Surgery11
Rehabilitation Services3
$50 copay
$40 copay
Chiropractic Care3
X-rays and Diagnostic Imaging
30%
coinsurance after deductible
$20 copay
Imaging
CT/PT Scans MRI's11
$40 copay
Laboratory12
no no charge
no no deductible
no no charge
no no deductible
Durable Medical Equipment
50% coinsurance after deductible
50% coinsurance no deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
30%
coinsurance after deductible
20%
coinsurance after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder $50 copay
$40 copay
24