Page 35 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

IN-NETWORK
$20/$40 $250/DAY
OUT-OF-NETWORK
IN-NETWORK
$20/$40 $0/DAY
OUT-OF-NETWORK
IN-NETWORK
$10/$20 $0/DAY
OUT-OF-NETWORK
$0/$0
$1 000/$3 000 000 $0/$0
$1 000/$3 000 000 $0/$0
$500/$1 500 500 $2 500/$5 000 $7 500/$15 000 $2 000/$4 000 000 $6 000/$12 000 000 $1 500/$3 000 $4 500/$9 000 $20 copay
30% coinsurance after deductible
$20 copay
30% coinsurance after deductible
$10 copay
20% coinsurance after deductible
$40 copay
30% coinsurance after deductible
$40 copay
30% coinsurance after deductible
$20 copay
20% 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
30% coinsurance after deductible
$75 copay
30% coinsurance after deductible
$75 copay
20% coinsurance after deductible
$250 copay
(max of 5 5 5 days $1 250)9
30% coinsurance after deductible
no charge
30% coinsurance after deductible
no charge
20% coinsurance after deductible
$125 copay
$40 copay
30% coinsurance after deductible
$40 copay
30% coinsurance after deductible
$20 copay
20% coinsurance after deductible
$40 copay
30% coinsurance after deductible
$40 copay
30% coinsurance after deductible
$20 copay
20% coinsurance after deductible
$80 copay
$80 copay
$40 copay
no charge
30% coinsurance after deductible
no charge
30% coinsurance after deductible
no charge
20% coinsurance after deductible
50% coinsurance 50% coinsurance after deductible
50% coinsurance 50% coinsurance after deductible
50% coinsurance 50% coinsurance after deductible
$250 copay
(max of 5 5 5 days $1 250)9
30% coinsurance after deductible
no charge
30% coinsurance after deductible
no charge
20% coinsurance after deductible
$40 copay
30% coinsurance after deductible
$40 copay
30% coinsurance after deductible
$20 copay
20% coinsurance after deductible
2021 Large Group Plans 33
Please see footnotes on page 45