Page 36 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

PPO HSA
MEDICAL BENEFITS
IN-NETWORK
$2 50010 /$5 000
HSA
$2 500/30% $7/$35/$50 RX4
OUT-OF-NETWORK
Deductible — individual/family
$5 00010 /$10 000
000
Maximum Out-of-Pocket — individual/family
$5 000/$10 0001 $10 000/$20 000
000
Primary Care Visits
30% coinsurance after deductible
50% coinsurance after deductible
Specialist Visits
30% coinsurance after deductible
50% coinsurance after deductible
Emergency Room
Urgent Care Services
30% coinsurance after deductible
Covered at in-network level
50% coinsurance after deductible
Inpatient Hospital Services
(including maternity)11
30% coinsurance after deductible
50% coinsurance after deductible
Outpatient Surgery11
Rehabilitation Services3
Chiropractic Care3
X-rays and Diagnostic Imaging
30% coinsurance after deductible
no charge after deductible
50% coinsurance after deductible
50% coinsurance after deductible
Imaging
CT/PT Scans MRI's11
30% coinsurance after deductible
Laboratory12
no charge after deductible
50% coinsurance after deductible
Durable Medical Equipment
Inpatient Treatment — Mental Behavioral Health/ Substance Use Disorder11
50% coinsurance after deductible
30% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
Outpatient Treatment — Mental Behavioral Health/ Substance Use Disorder 30% coinsurance after deductible
50% coinsurance after deductible
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