Benefits at a Glance - 2015Individual and Family
Choose the best plan for you and your family.Use this brochure to compare plans and cost-sharing.
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Choose the best health plan for you
Choosing a health plan is a big decision. But the good news is, you don’t have to make it alone. We’re here to help you — whether it’s to explain the different types of plans or to help you figure out which one makes the most sense for you.
Everything you need to get started is here. With this booklet, you’ll be able to look at plans side by side, so you can see how much you’ll pay when you receive covered services.
PLAN NAME4
Denotes On
Exchange
NetworkIndividual / Family
Deductible
Maximum Out of Pocket
Individual / FamilyPrimary Care Visits Specialist Visits
Preventive CareScreenings,
Immunizations
X-rays and Diagnostic Imaging
ImagingCT / PT scans, MRIs
LaboratoryOutpatient SurgeryAmbulatory Surgical
Inpatient Hospital Services
Emergency Room1Urgent Care
Services
Inpatient Treatment Mental / Behavioral Health, Substance Abuse Disorder
Outpatient Treatment
Mental / Behavioral Health, Substance Abuse Disorder
Physical and Occupational
Therapy30 visits / calendar
year2
Speech and Cognitive Therapy 30 visits / calendar
year2
Chiropractic Care 30 visits / calendar year
Pediatric Routine Eye Exam4,5
Pediatric Eyeglasses or Contact Lenses4,5
Generic 30 Day Supply5
Brand 30 Day Supply5
Non-Preferred Brand
30 Day Supply5
IHC Platinum EPO Local Value12 $15 / $30
In Network $0 $3,500 / $7,000 $15 copay $30 copayno charge,
no deductible$30 copay $60 copay
no charge, no deductible
no charge, no deductible
no charge, no deductible
$100 copay $75 copayno charge,
no deductible$30 copay $30 copay $30 copay $30 copay
no charge, no deductible
no charge, no deductible
$10 copay $40 copay $60 copay
IHC Platinum EPO Regional Preferred $15 / $30
In Network $0 $3,500 / $7,000 $15 copay $30 copayno charge,
no deductible$30 copay $60 copay
no charge, no deductible
no charge, no deductible
no charge, no deductible
$100 copay $75 copayno charge,
no deductible$30 copay $30 copay $30 copay $30 copay
no charge, no deductible
no charge, no deductible
$10 copay $40 copay $60 copay
IHC Platinum HMO Local Value12
$15 / $30In Network $0 $3,000 / $6,000 $15 copay $30 copay
no charge, no deductible
$30 copay $60 copayno charge,
no deductible$225 copay
$225 copay / day, up to 5 days
$75 copay $50 copay$225 copay / day,
up to 5 days$30 copay $30 copay $30 copay $30 copay
no charge, no deductible
no charge, no deductible
$10 copay $40 copay $60 copay
IHC Platinum HMO Regional Preferred $15 / $30
In Network $0 $3,000 / $6,000 $15 copay $30 copayno charge,
no deductible$30 copay $60 copay
no charge, no deductible
$225 copay$225 copay / day,
up to 5 days$75 copay $50 copay
$225 copay / day, up to 5 days
$30 copay $30 copay $30 copay $30 copayno charge,
no deductibleno charge,
no deductible$10 copay $40 copay $60 copay
IHC Platinum POS Plus National Access $15 / $25 4
In Network $0 $4,000 / $8,000 $15 copay $25 copayno charge,
no deductible$25 copay $50 copay
no charge, no deductible
$250 copay$300 / day, up to 5 days
$100 copay $50 copay$300 / day, up to 5 days
$25 copay $25 copay $25 copay $25 copayno charge,
no deductibleno charge,
no deductible$10 copay $40 copay $60 copay
Out of Network $3,000 / $6,000 $8,000 / $16,000 30%, after deductible 30%, after deductibleno charge,
no deductible630%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible $100 copay $50 copay 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered not covered
IHC Platinum POS Plus Regional Preferred $15 / $25
In Network $0 $4,000 / $8,000 $15 copay $25 copayno charge,
no deductible$25 copay $50 copay
no charge, no deductible
$250 copay$300 / day, up to 5 days
$100 copay $50 copay$300 / day, up to 5 days
$25 copay $25 copay $25 copay $25 copayno charge,
no deductibleno charge,
no deductible$10 copay $40 copay $60 copay
Out of Network $3,000 / $6,000 $8,000 / $16,000 30%, after deductible 30%, after deductibleno charge,
no deductible630%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible $100 copay $50 copay 30%, after deductible
30%, after deductible
30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered not covered
IHC Platinum POS Plus Local Value12 $15 / $25
In Network $0 $4,000 / $8,000 $15 copay $25 copayno charge,
no deductible$25 copay $50 copay
no charge, no deductible
$250 copay$300 / day, up to 5 days
$100 copay $50 copay$300 / day, up to 5 days
$25 copay $25 copay $25 copay $25 copayno charge,
no deductibleno charge,
no deductible$10 copay $40 copay $60 copay
Out of Network $3,000 / $6,000 $8,000 / $16,000 30%, after deductible 30%, after deductibleno charge,
no deductible630%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible $100 copay $50 copay 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered not covered
PLATINUM Benefits at a Glance INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS
PLAN NAME4
Denotes On
Exchange
NetworkIndividual / Family
Deductible
Maximum Out of Pocket
Individual / FamilyPrimary Care Visits Specialist Visits
Preventive CareScreenings,
Immunizations
X-rays and Diagnostic Imaging
ImagingCT / PT scans, MRIs
LaboratoryOutpatient SurgeryAmbulatory Surgical
Inpatient Hospital Services
Emergency Room1Urgent Care
Services
Inpatient Treatment Mental / Behavioral Health, Substance Abuse Disorder
Outpatient Treatment
Mental / Behavioral Health, Substance Abuse Disorder
Physical and Occupational
Therapy30 visits / calendar
year2
Speech and Cognitive Therapy 30 visits / calendar
year2
Chiropractic Care 30 visits / calendar year
Pediatric Routine Eye Exam4,5
Pediatric Eyeglasses or Contact Lenses4,5
Generic 30 Day Supply5
Brand 30 Day Supply5
Non-Preferred Brand
30 Day Supply5
IHC Gold EPO Local Value12 $30 / $50
In Network $1,000 / $2,000 $5,000 / $10,000 $30 copay $50 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
20%, after deductible 20%, after deductible $100 copay $75 copay20%,
after deductible$50 copay $50 copay $50 copay $50 copay
no charge, no deductible
no charge, no deductible
$10 copay $40 copay $60 copay
IHC Gold EPO Regional Preferred $30 / $50 4 In Network $1,000 / $2,000 $5,000 / $10,000 $30 copay $50 copay
no charge, no deductible
$50 copay $100 copayno charge,
no deductible20%, after deductible 20%, after deductible $100 copay $75 copay
20%, after deductible
$50 copay $50 copay $50 copay $50 copayno charge,
no deductibleno charge,
no deductible$10 copay $40 copay $60 copay
IHC Gold EPO National Access $30 / $50 4 In Network $1,000 / $2,000 $5,000 / $10,000 $30 copay $50 copay
no charge, no deductible
$50 copay $100 copayno charge,
no deductible20%, after deductible 20%, after deductible $100 copay $75 copay
20%, after deductible
$50 copay $50 copay $50 copay $50 copayno charge,
no deductibleno charge,
no deductible$10 copay $40 copay $60 copay
IHC Gold EPO HSA Local Value12 80% / 80% 4 In Network $1,300 / $2,600 $2,500 / $5,000 20%, after deductible 20%, after deductible
no charge, no deductible
20%, after deductible 20%, after deductibleno charge,
after deductible20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible
no charge, no deductible
no charge, no deductible
$10 copay, after deductible
$40 copay, after deductible
$60 copay, after deductible
IHC Gold EPO HSA Regional Preferred 80% / 80%
In Network $1,300 / $2,600 $2,500 / $5,000 20%, after deductible 20%, after deductibleno charge,
no deductible20%, after deductible 20%, after deductible
no charge, after deductible
20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductibleno charge,
no deductibleno charge,
no deductible$10 copay,
after deductible$40 copay,
after deductible$60 copay,
after deductible
IHC Gold HMO Local Value12 $15 / $30 4 In Network $2,000 / $4,000 $4,650 / $9,300 $15 copay $30 copay
no charge, no deductible
$50 copay $100 copayno charge,
no deductible40%, after deductible 40%, after deductible $100 copay $85 copay
40%, after deductible
$30 copay $30 copay $30 copay $30 copayno charge,
no deductibleno charge,
no deductible$10 copay $40 copay $60 copay
IHC Gold HMO Regional Preferred $15 / $30
In Network $2,000 / $4,000 $4,650 / $9,300 $15 copay $30 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
40%, after deductible 40%, after deductible $100 copay $85 copay40%,
after deductible$30 copay $30 copay $30 copay $30 copay
no charge, no deductible
no charge, no deductible
$10 copay $40 copay $60 copay
IHC Gold EPO Community Advantage7,14
$10 / $20 4
Tier 1
$500 / $1,0008 $4,250 / $8,5009
$10 copay $20 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
10%, after deductible 10%, after deductible $50 copay $35 copay10%,
after deductible$20 copay $20 copay $20 copay $20 copay
no charge, no deductible
no charge, no deductible
$10 copay $40 copay $60 copay
Tier 2 $50 copay $75 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
50%, after deductible 50%, after deductible $100 copay $85 copay50%,
after deductible$75 copay $75 copay $75 copay $75 copay
no charge, no deductible
no charge, no deductible
$10 copay $40 copay $60 copay
GOLD Benefits at a Glance INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS
IHC
IHC
All plans within this brochure reflect member cost-sharing.
54 amerihealthnj.com 888-879-5331
PLAN NAME4
Denotes On
Exchange
NetworkIndividual / Family
Deductible
Maximum Out of Pocket
Individual / FamilyPrimary Care Visits Specialist Visits
Preventive CareScreenings,
Immunizations
X-rays and Diagnostic Imaging
ImagingCT / PT scans, MRIs
LaboratoryOutpatient SurgeryAmbulatory Surgical
Inpatient Hospital Services
Emergency Room1Urgent Care
Services
Inpatient Treatment Mental / Behavioral Health, Substance Abuse Disorder
Outpatient Treatment
Mental / Behavioral Health, Substance Abuse Disorder
Physical and Occupational
Therapy30 visits / calendar
year2
Speech and Cognitive Therapy 30 visits / calendar
year2
Chiropractic Care 30 visits / calendar year
Pediatric Routine Eye Exam3,4
Pediatric Eyeglasses or Contact Lenses3,4
Generic 30 Day Supply5
Brand 30 Day Supply5
Non-Preferred Brand
30 Day Supply5
IHC Silver HMO Local Value12
$50 / $754 In Network $2,500 / $5,000 $6,350 / $12,700 $50 copay $75 copay
no charge, no deductible
$50 copay $100 copayno charge,
no deductible50%, after deductible 50%, after deductible
$100 copay, after deductible
$85 copay 50%, after deductible $75 copay $75 copay $75 copay $75 copayno charge,
no deductibleno charge,
no deductible50%, up to $125 max,
no deductible50%, up to $125 max,
no deductible50%, up to $125 max,
no deductible
IHC Silver HMO Regional Preferred $50 / $75
In Network $2,500 / $5,000 $6,350 / $12,700 $50 copay $75 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
50%, after deductible 50%, after deductible$100 copay,
after deductible$85 copay 50%, after deductible $75 copay $75 copay $75 copay $75 copay
no charge, no deductible
no charge, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
IHC Silver EPO HSA Local Value12
$50 / $754 In Network $1,800 / $3,600 $4,500 / $9,000
$50 copay, after deductible
$75 copay, after deductible
no charge, no deductible
$50 copay, after deductible
$100 copay, after deductible
no charge, after deductible
30%, after deductible$500 copay / day up to 5 days, after deductible
$100 copay, after deductible
$85 copay, after deductible
$500 copay / day up to 5 days, after
deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
no charge, no deductible
no charge, no deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
IHC Silver EPO HSA Regional Preferred $50 / $75
In Network $1,800 / $3,600 $4,500 / $9,000$50 copay,
after deductible$75 copay,
after deductibleno charge,
no deductible$50 copay,
after deductible$100 copay,
after deductibleno charge,
after deductible30%, after deductible
$500 copay / day up to 5 days, after deductible
$100 copay, after deductible
$85 copay, after deductible
$500 copay / day up to 5 days, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
no charge,no deductible
no charge,no deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
IHC Silver EPO HSA Tier 1 Advantage11,12 $50 / $75
4
Tier 1
$1,350 / $2,7008 $5,750 / $11,5009
$50 copay, after deductible
$75 copay, after deductible
no charge, no deductible
50%, after deductible 50%, after deductibleno charge,
after deductible10%, after deductible 10%, after deductible
$100 copay, after deductible
$75 copay, after deductible
10%, after deductible$75 copay,
after deductible$75 copay,
after deductible$75 copay,
after deductible$75 copay,
after deductibleno charge,
no deductibleno charge,
no deductible$7 copay,
after deductible50%, up to $125 max,
after deductible50%, up to $125 max,
after deductible
Tier 2$50 copay,
after deductible$75 copay,
after deductibleno charge,
no deductible50%, after deductible 50%, after deductible
no charge, after deductible
50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible$75 copay, after
deductible$75 copay,
after deductible$75 copay,
after deductible$75 copay,
after deductibleno charge,
no deductibleno charge,
no deductible$7 copay,
after deductible50%, up to $125 max,
after deductible50%, up to $125 max,
after deductible
IHC Silver EPO Community Advantage7,14
$15 / $354
Tier 1
$2,000 / $4,0008 $6,350 / $12,7009
$15 copay $35 copayno charge,
no deductible50%, after deductible 50%, after deductible
no charge, no deductible
20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible $35 copay $35 copay $35 copay $35 copayno charge,
no deductibleno charge,
no deductible$7 copay
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
Tier 2 $50 copay $75 copayno charge,
no deductible50%, after deductible 50%, after deductible
no charge no deductible
50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible $75 copay $75 copay $75 copay $75 copayno charge,
no deductibleno charge,
no deductible$7 copay
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
IHC Silver EPO HSA Local Value12
90% / 90%In Network $2,000 / $4,000 $6,450 / $12,900 10%, after deductible
10%, after deductible
no charge, no deductible
10%, after deductible 10%, after deductibleno charge,
after deductible10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible
no charge, no deductible
no charge, no deductible
$10 copay, after deductible
$40 copay, after deductible
$60 copay, after deductible
IHC Silver EPO HSA Regional Preferred 90% / 90%
In Network $2,000 / $4,000 $6,450 / $12,900 10%, after deductible 10%, after deductibleno charge,
no deductible10%, after deductible 10%, after deductible
no charge, after deductible
10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductibleno charge,
no deductibleno charge,
no deductible$10 copay,
after deductible$40 copay,
after deductibwle$60 copay,
after deductible
IHC Silver POS Plus Local Value12
$40 / $50
In Network $2,500 / $5,000 $6,350 / $12,700 $40 copay $50 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
30%, after deductible 30%, after deductible$100 copay,
after deductible$85 copay 30%, after deductible $50 copay $50 copay $50 copay $50 copay
no charge, no deductible
no charge, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
Out of Network $5,000 / $10,000 $12,700 / $25,400 50%, after deductible 50%, after deductibleno charge,
no deductible650%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
$100 copay, after deductible
$85 copay 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible not covered not covered not covered not covered not covered
IHC Silver POS Plus Regional Preferred $40 / $50
In Network $2,500 / $5,000 $6,350 / $12,700 $40 copay $50 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
30%, after deductible 30%, after deductible$100 copay,
after deductible$85 copay 30%, after deductible $50 copay $50 copay $50 copay $50 copay
no charge, no deductible
no charge, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
Out of Network $5,000 / $10,000 $12,700 / $25,400 50%, after deductible 50%, after deductibleno charge,
no deductible650%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
$100 copay, after deductible
$85 copay 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible not covered not covered not covered not covered not covered
IHC Silver POS Plus National Access $40 / $50
4
In Network $2,500 / $5,000 $6,350 / $12,700 $40 copay $50 copayno charge,
no deductible$50 copay $100 copay
no charge, no deductible
30%, after deductible 30%, after deductible$100 copay,
after deductible$85 copay 30%, after deductible $50 copay $50 copay $50 copay $50 copay
no charge, no deductible
no charge, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
50%, up to $125 max, no deductible
Out of Network $5,000 / $10,000 $12,700 / $25,400 50%, after deductible 50%, after deductibleno charge,
no deductible650%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
$100 copay, after deductible
$85 copay 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible not covered not covered not covered not covered not covered
SILVER Benefits at a GlanceIHC INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS
PLAN NAME4
Denotes On
Exchange
NetworkIndividual / Family
Deductible
Maximum Out of Pocket
Individual / FamilyPrimary Care Visits Specialist Visits
Preventive CareScreenings,
Immunizations
X-rays and Diagnostic Imaging
ImagingCT / PT scans, MRIs
LaboratoryOutpatient SurgeryAmbulatory Surgical
Inpatient Hospital Services
Emergency Room1Urgent Care
Services
Inpatient Treatment Mental / Behavioral Health, Substance Abuse Disorder
Outpatient Treatment
Mental / Behavioral Health, Substance Abuse Disorder
Physical and Occupational
Therapy30 visits / calendar
year2
Speech and Cognitive Therapy 30 visits / calendar
year2
Chiropractic Care 30 visits / calendar year
Pediatric Routine Eye Exam3,4
Pediatric Eyeglasses or Contact Lenses3,4
Generic 30 Day Supply5
Brand 30 Day Supply5
Non-Preferred Brand
30 Day Supply5
IHC Bronze EPO HSA Local Value12
50% / 50%4 In Network $2,500 / $5,000 $6,450 / $12,900 50%, after deductible 50%, after deductible
no charge, no deductible
50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductibleno charge,
no deductibleno charge,
no deductible50%, after deductible 50%, after deductible 50%, after deductible
IHC Bronze EPO HSA Regional Preferred 50% / 50%
4 In Network $2,500 / $5,000 $6,450 / $12,900 50%, after deductible 50%, after deductibleno charge,
no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
no charge, no deductible
no charge, no deductible
50%, after deductible 50%, after deductible 50%, after deductible
IHC Bronze EPO HSA National Access 50% / 50%
4 In Network $2,500 / $5,000 $6,450 / $12,900 50%, after deductible 50%, after deductibleno charge,
no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
no charge, no deductible
no charge, no deductible
50%, after deductible 50%, after deductible 50%, after deductible
IHC Bronze EPO HSA Tier 1 Advantage11,12 $50 / $75
4
Tier 1
$2,500 / $5,0008 $6,450 / $12,9009
$50 copay, after deductible
$75 copay, after deductible
no charge, no deductible
50%, after deductible 50%, after deductible 50%, after deductible 20%, after deductible 20%, after deductible 50%, after deductible$75 copay, after
deductible20%, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
no charge, no deductible
no charge, no deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
Tier 2$50 copay,
after deductible$75 copay,
after deductibleno charge,
no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
no charge, no deductible
no charge, no deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
IHC Bronze EPO HSA Community Advantage7,14 $25 / $50
4
Tier 1
$2,500 / $5,0008 $6,450 / $12,9009
$25 copay, after deductible
$50 copay, after deductible
no charge, no deductible
50%, after deductible 50%, after deductible 50%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible$50 copay,
after deductible$50 copay,
after deductible$50 copay,
after deductible$50 copay,
after deductibleno charge,
no deductibleno charge,
no deductible50%, up to $125 max,
after deductible50%, up to $125 max,
after deductible50%, up to $125 max,
after deductible
Tier 2$50 copay,
after deductible$75 copay,
after deductibleno charge,
no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
$75 copay, after deductible
no charge, no deductible
no charge, no deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
50%, up to $125 max, after deductible
BRONZE Benefits at a GlanceIHC INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS
PLAN NAME4
Denotes On
Exchange
NetworkIndividual / Family
Deductible
Maximum Out of Pocket
Individual / FamilyPrimary Care Visits Specialist Visits
Preventive CareScreenings,
Immunizations
X-rays and Diagnostic Imaging
ImagingCT / PT scans, MRIs
LaboratoryOutpatient SurgeryAmbulatory Surgical
Inpatient Hospital Services
Emergency Room1Urgent Care
Services
Inpatient Treatment Mental / Behavioral Health, Substance Abuse Disorder
Outpatient Treatment
Mental / Behavioral Health, Substance Abuse Disorder
Physical and Occupational
Therapy30 visits / calendar
year2
Speech and Cognitive Therapy 30 visits / calendar
year2
Chiropractic Care 30 visits / calendar year
Pediatric Routine Eye Exam3,4
Pediatric Eyeglasses or Contact Lenses3,4
Generic 30 Day Supply5
Brand 30 Day Supply5
Non-Preferred Brand
30 Day Supply5
IHC Local Value Simple Saver12,13 4 In Network $6,600 / $13,200 $6,600 / $13,200$30 copay,
no deductible10
no charge, after deductible
no charge, no deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
IHC Regional Preferred Simple Saver13 4 In Network $6,600 / $13,200 $6,600 / $13,200$30 copay,
no deductible10
no charge, after deductible
no charge, no deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
no charge, after deductible
CATASTROPHIC Benefits at a GlanceIHC INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS
76 amerihealthnj.com 888-879-5331
DENTAL15,16 Healthy Chompers Child Healthy Chompers Child with Adult Preventive
Child Ages 0-18 (benefits through end of contract year in which
child reaches age 19)
Child Ages 0-18 (benefits through end of contract year in which
child reaches age 19)
Adult
Age 19+
Deductible $350 per child $350 per child $0
Annual MaximumIn-network: None
Out-of-network: $1,000In-network: None
Out-of-network: $1,000$1,000
Out of Pocket Maximum$350 for 1 child
$700 for 2+ children$350 for 1 child
$700 for 2+ childrenN / A
Preventive and Diagnostic• 90% exams and cleanings, not subject to deductible• 50% x-rays and flouride, not subject to deductible• 50% sealants and space maintainers, after deductible
• 90% exams and cleanings, not subject to deductible• 50% x-rays and flouride, not subject to deductible• 50% sealants and space maintainers, after deductible
100% exams, cleanings, and x-rays
Basic 50%, after deductible 50%, after deductible• Not covered• Discounts available from network dentists – 36%
average discount
Major 50%, after deductible 50%, after deductible• Not covered• Discounts available from network dentists – 36%
average discount
Medically Necessary Orthodontia 50%, after deductible 50%, after deductible N / A
FOOTNOTES:1 Emergency room copay waived if admitted.2 Members can utilize 30 visits per therapy per calendar year. 3 Available for members up to age 19, covered once per calendar year.4 Davis Vision administers the pediatric vision program. For frames to be covered in full, choose from Davis Vision’s Pediatric frame selection. 5 Prescription mail order benefit is available at 2x applicable cost-sharing for a 90 day supply.6 No charge, no deductible for up to $750 per child up to 1 year of age and $500 per covered person maximum over the age of 1.7 Community Advantage plans are only available to individuals and employers based in Atlantic, Burlington, Camden, Cape May, and Gloucester Counties.8 Deductible is combined for Tier 1 and Tier 2.9 Out-of-pocket maximum is combined for Tier 1 and Tier 2. 10 $30 copay, no deductible for the first 3 visits per calendar year, then remaining visits covered at 100%, after deductible.11 Tier 1 facility providers are an enhancement to your benefits. Tier 2 facility providers are AmeriHealth New Jersey Local Value network providers. 12 The Local Value network is not available in Hunterdon County. 13 Catastrophic plans are only available for qualified individuals.14 Tier 1 professional and facility providers are an enhancement to your benefits. Tier 2 professional and facility providers are AmeriHealth New Jersey Local Value network providers.15 Healthy Chompers plans are underwritten and administered by United Concordia.16This is a summary of benefits and limitations and exclusions apply.
Important plan information
The benefits summaries in this brochure represent only a partial listing of benefits of the plans. Benefits and exclusions may be further defined by medical policy. These managed care plans may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you need more information, call 888-879-5331 for additional assistance.
2015 Dental Overview
The Patient Protection and Affordable Care Act (PPACA) requires that all members have pediatric dental essential health benefits. By choosing one of the following dental plans, you will meet this requirement. If you do not select one of these plans, proof that you have pediatric dental coverage under another plan will be required.
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© 2014 AmeriHealth | 18190 | 2014 OctoberAmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.
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