Page 37 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

IN-NETWORK
HSA
$2 000/10% $7/$35/$50 RX4
OUT-OF-NETWORK
IN-NETWORK
HSA
$1 500/0% $10/$40/$60 RX4
OUT-OF-NETWORK
$2 00010 /$4 000
000
$5 00010 /$10 000
000
$1 50010 /$3 000
$3 00010 /$6 000
000
$5 000/$10 0001 $10 000/$20 000
000
$1 650/$3 300
$15 000/$30 000
000
10% coinsurance after deductible
40% coinsurance after deductible
no charge after deductible
40% coinsurance after deductible
10% coinsurance after deductible
40% coinsurance after deductible
no charge after deductible
40% coinsurance after deductible
10% coinsurance after deductible
Covered at in-network level
40% coinsurance after deductible
no charge after deductible
Covered at in-network level
40% coinsurance after deductible
10% coinsurance after deductible
40% coinsurance after deductible
no charge after deductible
40% coinsurance after deductible
10% coinsurance after deductible
40% coinsurance after deductible
40% coinsurance after deductible
no charge after deductible
no charge after deductible
40% coinsurance after deductible
no charge after deductible
40% coinsurance after deductible
10% coinsurance after deductible
no charge after deductible
40% coinsurance after deductible
no charge after deductible
40% coinsurance after deductible
50% coinsurance after deductible
10% coinsurance after deductible
50% coinsurance after deductible
50% coinsurance after deductible
no charge after deductible
50% coinsurance after deductible
40% coinsurance after deductible
40% coinsurance after deductible
10% coinsurance after deductible
40% coinsurance after deductible
no charge after deductible
40% coinsurance after deductible
2021 Large Group Plans 35 Please see footnotes on page 45