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Benefits Summary

AmeriHealth® HMO


Benefits IHC Preferred IHC Basic IHC 50 IHC 30/50 IHC 30 IHC 15
Benefits Summary PDF
Primary Care Physician $30 copay $30 copay $50 copay $30 copay $30 copay $15 copay
Specialist Office Visits $30 copay $30 copay; plan pays a maximum of $700 per calendar year $50 copay $50 copay $30 copay $15 copay
Outpatient X-Ray and Lab Services 100% covered 100% covered $50 copay $50 copay $30 copay $15 copay
Well Baby/Child Care $30 copay $30 copay $50 copay $30 copay $30 copay $15 copay
Inpatient Hospital Services $500 copay/ confinement, then covered at 100% $500 copay/ confinement, then covered at 100%; maximum 90 days/ calendar year $500 copay/day;
maximum 5 days/ admission; $5,000 maximum copay/ calendar year		 $300copay/ day;
maximum 5 days/ admission; $3,000 maximum copay/ calendar year		 $300 copay/ day;
maximum 5 days/admission; $3,000 maximum copay/ calendar year		 $150 copay/ day.
maximum 5 days/admission; $1,500 maximum copay/ calendar year
Prenatal Care $50 copay for initial visit; subsequent visits are covered in full.
Inpatient: see Inpatient Hospital Care.		 See Inpatient Hospital Care; First three prenatal visits are covered as specialists office visits. Delivery and newborn are covered; Prenatal (with the exception of first three office visits and Postnatal not covered) $50 copay for the initial visit $30 copay for the initial visit $25 copay for the initial visit; subsequent visits are covered in full $25 copay for the initial visit; subsequent visits are covered in full
Emergency Room $100 copay per visit $100 copay per visit $100 copay per visit* $100 copay per visit* $100 copay per visit* $100 copay per visit*
Outpatient and Ambulatory Surgery $250 copay per surgery, then 100% $250 copay per surgery, then 100% Facility – $100 copay;
Practitioner – $50 copay		 Facility – $100 copay;
Practitioner – $50 copay		 Facility – $30 copay;
Practitioner – $30 copay		 Facility – $15 copay;
Practitioner – $15 copay
Biologically Based Mental Illness Outpatient: plan pays 70%; 30 visits/ calendar year
Inpatient: $500 copay/ confinement		 Outpatient: plan pays 70%; 30 visits/calendar year
Inpatient: $500 copay/ confinement; 90 days maximum/ calendar year		 Outpatient: $50 copay
Inpatient: $500 copay/ day; maximum 5 days/admission; $5,000 maximum copay/ year		 Outpatient: $50 copay
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/year		 Outpatient: $30 copay
Inpatient: $250 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year		 Outpatient: $15 copay
Inpatient: $150 copay/ day; maximum 5 days/ admission; $1,500 maximum copay/ year
Non-Biologically Based Mental Illness Not covered Not covered Outpatient: $50 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $500 copay/ day; maximum 5 days/admission; $5,000 maximum copay/ year combined with substance abuse		 Outpatient: $50 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/year combined with substance abuse		 Outpatient: $30 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year combined with substance abuse		 Outpatient: $15 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $150 copay/ day; maximum 5 days/ admission; $1,500 maximum copay/ year combined with substance abuse
Substance Abuse Outpatient: plan pays 70%; 30 visits/ calendar year combined with alcohol abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with alcohol abuse		 Outpatient: plan pays 70%; 30 visits/ calendar year combined with alcohol abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with alcohol abuse		 Outpatient: $50 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $500 copay/ day; maximum 5 days/ admission; $5,000 maximum copay/ year combined with non-biologically based mental illness		 Outpatient: $50 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year combined with non-biologically based mental illness		 Outpatient: $30 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year combined with non-biologically based mental illness		 Outpatient: $15 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $150 copay/ day; maximum 5 days/ admission; $1,500 maximum copay/ year combined with non-biologically based mental illness
Alcohol Abuse Outpatient: plan pays 70%; 30 visits/ calendar year combined with substance abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with substance abuse		 Outpatient: plan pays 70%; 30 visits/ calendar year combined with substance abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with substance abuse		 See biologically based mental illness See biologically based mental illness See biologically based mental illness See biologically based mental illness
Pre-Admission Testing 100% covered 100% covered $50 copay $50 copay $30 copay $15 copay
Prescription Drug Plan pays 50% up to $1,500 per person per year Not covered 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

* Credited toward inpatient admission, if admission occurs within 24 hours of emergency.

The listing of benefits and services is only a summary. For a more detailed description of benefits, exclusions, and limitations, refer to the IHC contract.