Page 48 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance

Prescription drug benefits (pg 36)
1 FutureScripts a a a a a a a a a a a a a CatamaranTM company company is an an an an an independent company company that provides pharmacy benefit management services 2 30-day supply
3 Prescription mail order benefit is available at two times the applicable cost-sharing for a a a a a a a a a a 90-day supply
Dental benefits (pg 37 – 39)
4 Members (subscribers or or covered dependents) with certain medical conditions must sign up for this program through My Dental Benefits on on UnitedConcordia com 5 5 Unmarried dependent dependent students covered to to age age 26 Groups with 51+ employees can customize the age age limits for dependents 6 Reimbursement is is based on our our schedule of maximum allowable charges (MACs) Network dentists agree to accept our our allowances as as payment in full for for covered services Non-network dentists may bill bill the the member for for any difference between our allowance and their fee (also known as balance billing) United Concordia Dental’s standard exclusions and and limitations apply Other out-of-network reimbursement levels are available 7 Other deductible and annual maximum amounts available based on group size Representative listing of of of covered services — certificate of of of coverage provides a a a a a detailed description of of of benefits Vision benefits (pg 40 – 43)
8 Allowances are up to the amount shown for each plan type 9 Enhanced $50 frame allowance is is available at at at all all Visionworks locations nationwide 10 Inclusive of of dilation when professionally indicated 11 Polycarbonate lenses are covered in full for dependent children monocular patients patients and patients patients with prescriptions +/- 6 00 diopters or or greater 12 Anything related to this discount is is is handled by QualSight Guardian benefits (pg 44)
13 Available on employer-funded Guardian products
MDLIVE provides telemedicine teledermatology and telebehavioral health services for AmeriHealth New Jersey members FutureScripts® provides pharmacy benefits management services for AmeriHealth New Jersey Dental plans are sold and administered by United Concordia Companies Inc AmeriHealth New Jersey vision benefits are administered by Davis Vision Guardian Group Accident Insurance Insurance Insurance Insurance Insurance Cancer Insurance Insurance Insurance Insurance Insurance Critical Illness Insurance Insurance Insurance Insurance Insurance Hospital Indemnity Insurance Insurance Insurance Insurance Insurance Life Insurance Insurance Insurance Insurance Insurance and Disability Insurance Insurance are are underwritten by The Guardian Life Insurance Insurance Company of America New York NY Products are are not available in all states Policy limitations and and exclusions apply Optional riders and/or features may incur additional costs These products
provide limited benefits Plan documents are the final arbiter of coverage Accident Insurance Insurance Policy Policy Form Form #GP-1-AC-IC-12 Cancer Insurance Insurance Policy Policy Form Form #GP-1-CAN-IC-12 Critical Illness Policy Policy Policy Policy Form Form Form #GC-CI-11 Hospital Indemnity Policy Policy Policy Policy Form Form Form #GP-1-HI-15 Term Life Life Insurance Policy Policy Policy Policy Form Form Form #GC-Life-15-1 0 AD&D Policy Policy Policy Policy Form Form Form #GC-ADD-15-1 0 0 0 0 Voluntary Term Term Term Life Policy Form Form Form #GP-1-R-ADCL1-00 Short Term Term Term Disability Form Form Form et al #GP-1-STD-15-1 0 0 0 0 Long Term Term Term Disability Form #GP-1-LTD-15-1 0 et al 46