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Benefits Summary

AmeriHealth® PPO High Deductible Health Plans

For your convenience, there are eight options for you to choose from when considering an AmeriHealth PPO High Deductible Health Plan. Please note: each option offers the same out-of-network benefits.

Options 5-8 can be viewed below.

Options 1 through 4

Option 1 Option 2 Option 3 Option 4 Out-of-Network
Product Code: HD1-HC1 HD1-HC2 HD2-HC1 HD2-HC2  
Calendar Year
Deductible1		 $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $2,000/$4,000 $5,000/$10,000
Coinsurance 100% 80% 100% 80% 50%
Calendar Year
Out-of-Pocket Maximum1		 $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $10,000/$20,000
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited $500,000
Primary Care Provider Office Visit 100% 80% 100% 80% 50%
OB-GYN Office Visit 100% 80% 100% 80% 50%
Specialist Office Visit 100% 80% 100% 80% 50%
Physical & Occupational Therapy
30 visits / cal year
combined in/out-of-network		 100% 80% 100% 80% 50%
Outpatient Lab/Pathology
(Outpatient facility & lab)		 100% 80% 100% 80% 50%
Outpatient X-Ray/Radiology/Diagnostic Services
- Routine Radiology/Diagnostic
– MRI/MRA, CT Scan/PET Scan*		 100% 80% 100% 80% 50%
Preventive Visits
Pediatric & Adult		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 50%
No deductible
Routine Gyn Exam/Pap
1 visit / cal year, regardless of age		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 50%
No deductible
Mammography 100%
No deductible		 100%
No deductible		 100%
No deductible		 100%
No deductible		 50%
No deductible
Pediatric Immunizations 100%
No deductible		 100%
No deductible		 100%
No deductible		 100%
No deductible		 50%
No deductible
Maternity, 1st visit 100% 80% 100% 80% 50%
Hospital Inpatient*
Unlimited days in-network		 100% 80% 100% 80% 50%, 70 days
Outpatient Surgery* 100% 80% 100% 80% 50%
Emergency Room 100% 80% 100% 80% Covered at in-network level
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Options 5 through 8

Option 5 Option 6 Option 7 Option 8 Out-of-Network
Product Code: HD3-HC1 HD3-HC2 HD4-HC1 HD4-HC2  
Calendar Year Deductible1 $2,500/$5,000 $2,500/$5,000 $3,000/$6,000 $3,000/$6,000 $5,000/$10,000
Coinsurance 100% 80% 100% 80% 50%
Calendar Year Out-of-Pocket Maximum1 $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $10,000/$20,000
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited $500,000
Primary Care Provider Office Visit 100% 80% 100% 80% 50%
OB-GYN Office Visit 100% 80% 100% 80% 50%
Specialist Office Visit 100% 80% 100% 80% 50%
Physical & Occupational Therapy
30 visits / cal year
combined in/out-of-network		 100% 80% 100% 80% 50%
Outpatient Lab/Pathology
(Outpatient facility & lab)		 100% 80% 100% 80% 50%
Outpatient X-Ray/Radiology/Diagnostic Services
- Routine Radiology/Diagnostic
– MRI/MRA, CT Scan/PET Scan*		 100% 80% 100% 80% 50%
Preventive Visits
Pediatric & Adult		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 50%
No deductible
Routine Gyn Exam/Pap
1 visit / cal year, regardless of age		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 $20 copay
No deductible		 50%
No deductible
Mammography 100%
No deductible		 100%
No deductible		 100%
No deductible		 100%
No deductible		 50%
No deductible
Pediatric Immunizations 100%
No deductible		 100%
No deductible		 100%
No deductible		 100%
No deductible		 50%
No deductible
Maternity, 1st visit 100% 80% 100% 80% 50%
Hospital Inpatient*
Unlimited days in-network		 100% 80% 100% 80% 50%, 70 days
Outpatient Surgery* 100% 80% 100% 80% 50%
Emergency Room 100% 80% 100% 80% Covered at in-network level
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* Pre-authorization is required for certain services. For detail please refer to the group contract. AmeriHealth PPO members may be held responsible for financial penalties if they do not pre-authorize services when using an out-of-network provider. Members will be subject to 20 percent reduction in benefits if prior approval is not obtained for inpatient/outpatient treatment services for PPO out-of-network.

1 Single deductible and out-of-pocket maximum apply when an individual is enrolled without dependents. Family deductible and out-of-pocket maximum apply when an individual and one or more dependents are enrolled. Prior to benefits being paid, the entire family deductible must be met. Please note: Out-of-Pocket Maximums represent the 2008 levels for HSA-qualified High Deductible Health Plans. These amounts may be adjusted annually on January 1 to correspond with cost-of-living adjustments made by the Treasury Department.

This Product Grid is a highlight of benefits available and is provided as a sales document to be used by AmeriHealth sales representatives and those appointed/contracted to sell our products. For specific details, conditions and exclusions, please refer to the applicable group contracts. As terms/benefit provisions change periodically, please contact your AmeriHealth sales representative to ensure you possess the most current information. This Product Grid is the sole property of AmeriHealth and contains confidential and proprietary information. This grid and its contents should not be copied, disclosed or distributed to any third party/person without the prior written permission of AmeriHealth.