Page 47 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

Important health plan information
All health plans within this brochure reflect member cost-sharing The benefit benefit summaries in in in this this brochure brochure represent only a a a a a a a partial listing of of benefits of of the health plans Some services not shown in in in this this brochure brochure may require a a a a a a a a a a a higher member coinsurance than the the services shown Benefits and exclusions may may be be further defined by medical policy These managed care plans may may not cover cover all your your health health care care care expenses
Read your your contract carefully to determine which health health care care care services are are are are covered If you you you need more information
please contact your broker Network options (pg 4 – 5)
1 Data derived from the analysis of information
provided by a a a a a a a a a third-party vendor and is is subject to change 2 Coverage provided by Multiplan PHCS National Network AmeriHealth AmeriHealth New New Jersey Jersey members accessing care in in the AmeriHealth AmeriHealth New New Jersey Jersey service area must use the Regional Preferred network 3
The AmeriHealth New New Jersey Jersey service area area includes all New New Jersey Jersey and and Delaware counties counties and and nine Pennsylvania counties counties in in in the Philadelphia area area including Berks Bucks Chester Delaware Lancaster Lehigh Montgomery Northampton and Philadelphia 4 The Local Value Network is not available in Hunterdon County 5 AmeriHealth Advantage plans are only available to to employers based in in in the following counties: Atlantic Burlington Camden Cape May Essex Gloucester Hudson Mercer Middlesex Monmouth Ocean Somerset and Union Members can obtain services within the the listed counties at the the tier 1 level AmeriHealth Advantage Advantage tier tier 1 hospitals are subject to change AmeriHealth AmeriHealth Advantage Advantage members can access tier tier 2 providers within the AmeriHealth AmeriHealth New Jersey Local Value network network If a a a a a a a a a a 3-tier plan is selected AmeriHealth Advantage members can also access tier tier 3
3
providers within the Regional Preferred with with NY network network and National National Access Access providers through the the PHCS network National National Access Access is to be used when outside the the AmeriHealth New Jersey service area and NY 6 Access to the GHI/Emblem Network in New York is available for our EPO PPO and POS Plus plans Medical footnotes (pg 12 – 35)
1 2 3
4 5 6 7 8
9 10 11 12 13
14
For family plans no individual will exceed a a a a a $6 900 maximum out-of-pocket Emergency room copay not waived if admitted Visit limits may apply See benefit booklet for details Prescription mail order benefit is available at 2x applicable cost sharing for a a a a a a a a a a 90 day supply AmeriHealth Advantage plans are only available to to employers based in in in the following counties: Atlantic Burlington Camden Cape May Essex Gloucester Hudson Mercer Middlesex Monmouth Ocean Somerset and Union Members can obtain services within the the listed counties at the the tier tier tier 1 1 level AmeriHealth AmeriHealth Advantage Advantage tier tier tier 1 1 hospitals are subject to change AmeriHealth AmeriHealth Advantage Advantage members can access tier tier tier 2 providers within the AmeriHealth AmeriHealth New Jersey Local Value network If a a a a a a a a a a a 3-tier plan is selected AmeriHealth AmeriHealth Advantage members can also access tier tier 3
3
providers within the the Regional Preferred with with NY network network and National National Access Access providers through the the PHCS network network National National Access Access is to be used when outside the AmeriHealth New Jersey service area and NY Deductible is combined for tier tier 1 and tier tier 2 Out-of-pocket maximum is combined for tier tier 1 and tier tier 2 AmeriHealth AmeriHealth Hospital Advantage providers providers are are an an an enhancement to your benefits Tier 2 providers providers are are AmeriHealth AmeriHealth New Jersey Local Value network providers Copay Copay is is required per per day day day up to a a a a a a a a a a maximum of 5 days days per per admission Copay Copay waived if readmitted within 10 days days Individual deductible not applicable in in policies covering 2 or or more people Subject to preapproval Laboratory Corporation of America® Holdings (LabCorp) is AmeriHealth New Jersey’s exclusive outpatient laboratory provider To find your closest patient service center location visit LabCorp com Deductible accumulates across tier tier tier 1 tier tier tier 2 2 and tier tier tier 3
maximum deductible is $2 500/$5 000 Out-of-pocket is combined for tier tier tier 1 tier tier tier 2 and tier tier tier 3
2021 Large Group Plans 45