Page 34 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

POS PLUS
MEDICAL BENEFITS
Deductible — individual/family
IN-NETWORK
$0/$0
no charge
$30/$40 $300/DAY
OUT-OF-NETWORK
40% coinsurance after deductible
$2 000/$6 000 000 Maximum Out-of-Pocket — individual/family
$3 000/$6 000 000 $9 000/$18 000 000 Primary Care Visits
Specialist Visits
$30 copay
$40 copay
40% coinsurance after deductible
40% coinsurance after deductible
Emergency Room
$100 copay2
Covered at in-network level
Urgent Care Services
$75 copay
40% coinsurance after deductible
Inpatient Hospital Services
(including maternity)11
$300 copay/day (max of 5 5 days $1 500)9
Outpatient Surgery11
$150 copay
Rehabilitation Services3
Chiropractic Care3
$40 copay
40% coinsurance after deductible
X-rays and Diagnostic Imaging
$40 copay
$80 copay
40% coinsurance after deductible
Imaging
CT/PT Scans MRI's11
Laboratory12
40% coinsurance after deductible
Durable Medical Equipment
50% coinsurance 50% coinsurance after deductible
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
$300 copay/day (max of 5 5 days $1 500)9
40% coinsurance after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder $40 copay
40% coinsurance after deductible
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