Page 29 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

HSA
$30/$50 $2 500/0% $25/$50/$75 RX4
IN-NETWORK
no charge after deductible
HSA
$1 500/50% $7/50%/$125 RX4
IN-NETWORK
50% coinsurance after deductible
HSA
$1 500/30% $7/50%/$125 RX4
IN-NETWORK
HSA
$1 500/30% $10/$40/$60 RX4
IN-NETWORK
NEW PLAN
HSA
$2 500/0% $10/$40/$60 RX4
IN-NETWORK
$2 50010 /$5 000
$1 50010 /$3 000
$1 50010 /$3 000
$1 50010 /$3 000
$2 50010 /$5 000
$6 900/$13 8001
$2 500/$5 000
$3 000/$6 000
000
$3 000/$6 000
000
$3 000
000
/ $6 000
000
$30 copay after deductible
50% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
no charge after deductible
$50 copay after deductible
50% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
no charge after deductible
$100 copay after deductible2
50% coinsurance after deductible
30% after deductible
30% after deductible
no charge after deductible
$75 copay after deductible
30% coinsurance after deductible
30% coinsurance after deductible
no charge after deductible
no charge after deductible
50% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
no charge after deductible
$30 copay after deductible
no charge after deductible
50% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
no charge after deductible
no charge after deductible
no charge after deductible
no charge after deductible
no charge after deductible
no charge after deductible
50% coinsurance after deductible
no charge after deductible
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
30% coinsurance after deductible
50% coinsurance after deductible
30% coinsurance after deductible
50% coinsurance after deductible
no charge after deductible
no charge after deductible
50% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
no charge after deductible
2021 Large Group Plans 27
Please see footnotes on page 45