Page 33 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

IN-NETWORK
$30/$50 $2 000/30%
OUT-OF-NETWORK
50% coinsurance after deductible
IN-NETWORK
$30/$50 $1 500/20%
OUT-OF-NETWORK
40% coinsurance after deductible
IN-NETWORK
$20/$40 $1 000/10%
OUT-OF-NETWORK
$2 000/$4 000 000 $3 000/$6 000 000 $1 500/$3 000 $3 000/$6 000 000 $1 000/$2 000 000 $2 000/$4 000 000 $4 000/$8 000 000 $15 000/$30 000 000 $3 000/$6 000 000 $6 000/$12 000 000 $2 500/$5 000 $5 000/$10 000 000 $30 copay
50% coinsurance after deductible
$30 copay
40% coinsurance after deductible
$20 copay
30%
coinsurance after deductible
$50 copay
50% coinsurance after deductible
$50 copay
40% coinsurance after deductible
$40 copay
30%
coinsurance after deductible
$100 copay2
Covered at in-network level
$100 copay2
Covered at in-network level
$100 copay2
Covered at in-network level
$75 copay
50% coinsurance after deductible
$75 copay
40% coinsurance after deductible
$75 copay
30%
coinsurance after deductible
30%
coinsurance after deductible
20%
coinsurance after deductible
10%
coinsurance after deductible
30%
coinsurance after deductible
$50 copay
50% coinsurance after deductible
$50 copay
40% coinsurance after deductible
$40 copay
30%
coinsurance after deductible
$50 copay
50% coinsurance after deductible
$50 copay
40% coinsurance after deductible
$40 copay
30%
coinsurance after deductible
$100 copay
$100 copay
$80 copay
no charge no deductible
50% coinsurance after deductible
no charge no deductible
40% coinsurance after deductible
no charge no deductible
30%
coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
30%
coinsurance after deductible
50% coinsurance after deductible
20%
coinsurance after deductible
40% coinsurance after deductible
10%
coinsurance after deductible
30%
coinsurance after deductible
$50 copay
50% coinsurance after deductible
$50 copay
40% coinsurance after deductible
$40 copay
30%
coinsurance after deductible
2021 Large Group Plans 31
Please see footnotes on page 45