Page 28 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

EPO HSA
MEDICAL BENEFITS
Outpatient Surgery11
HSA
$2 500/50% $25/$50/$75 RX4
IN-NETWORK
50% coinsurance after deductible
NEW PLAN
HSA
$2 500/30% $25/$50/$75 RX4
IN-NETWORK
30% coinsurance after deductible
HSA
$2 500/20% $25/$50/$75 RX4
IN-NETWORK
20% coinsurance after deductible
Deductible — individual/family
$2 50010 /$5 000
$2 50010 /$5 000
$2 50010 /$5 000
Maximum Out-of-Pocket — individual/family
$6 900/$13 8001
$6 900/$13 8001
$5 000/$10 0001
Primary Care Visits
Specialist Visits
Emergency Room
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance after deductible
30% coinsurance after deductible
20% coinsurance after deductible
Urgent Care Services
Inpatient Hospital Services
(including maternity)11
Rehabilitation Services3
50% coinsurance after deductible
30% coinsurance after deductible
20% coinsurance after deductible
Chiropractic Care3
50% coinsurance after deductible
30% coinsurance after deductible
20% coinsurance after deductible
X-rays and Diagnostic Imaging
Imaging
CT/PT Scans MRI's11
Laboratory12
Durable Medical Equipment
no charge after deductible
50% coinsurance after deductible
50% coinsurance after deductible
no charge after deductible
50% coinsurance after deductible
30% coinsurance after deductible
no charge after deductible
50% coinsurance after deductible
20% coinsurance after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder 50% coinsurance after deductible
30% coinsurance after deductible
20% coinsurance after deductible
26