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Plan Options

• Health Plan

• AmeriHealth^® PPO
• AmeriHealth^® HMO
• AmeriHealth^® New Jersey EPO
• AmeriHealth 65^® HMO

Benefits at a Glance

AmeriHealth^® PPO

Benefits	IHC $25/$50/70%		IHC $30/$50/90%
Benefits at a Glance PDF	IHC $25/$50/70%		IHC $30/$50/90%
	In-network	Out-of-network	In-network	Out-of-network
Annual Deductible	Individual: $2,500 Family: $5,000	Individual: $7,500 Family: $15,000	Individual: $2,500 Family: $5,000	Individual: $5,000 Family: $10,000
Coinsurance	Plan pays 70%	Plan pays 50%	Plan pays 90%	Plan pays 70%
Maximum out-of-pocket	Individual: $5,000 Family: $10,000	Individual: $15,000 Family: $30,000	Individual: $5,000 Family: $10,000	Individual: $10,000 Family: $20,000
Primary Care Physician	$25 copay	50% subject to deductible	$30 copay	70% subject to deductible
Specialist Office Visits	$50 copay	50% subject to deductible	$50 copay	70% subject to deductible
Laboratory Services	100%; no deductible (when provided by network lab)	50% subject to deductible	100%; no deductible (when provided by network lab)	70% subject to deductible
Outpatient X-ray	70% subject to deductible	50% subject to deductible	90% subject to deductible	70% subject to deductible
Preventive Care For Adults and Children	Covered at 100%	Covered 100% to maximum benefit of $500 per covered person per calendar year; $750 for newborns until first birthday	Covered at 100%	Covered 100% to maximum benefit of $500 per covered person per calendar year; $750 for newborns until first birthday
Inpatient Hospital Services	70% subject to deductible	50% subject to deductible	90% subject to deductible	70% subject to deductible
Maternity	$25 copay for initial visit; subsequent visits covered in full. Maternity hospital: See Inpatient Hospital Services	50% subject to deductible. Maternity hospital: See Inpatient Hospital Services	$30 copay for initial visit; subsequent visits covered in full. Maternity hospital: See Inpatient Hospital Services	70% subject to deductible. Maternity hospital: See Inpatient Hospital Services
Emergency Room	$100 copay*	$100 copay*	$100 copay*	$100 copay*
Outpatient and Ambulatory Surgery	70% subject to deductible	50% subject to deductible	90% subject to deductible	70% subject to deductible
Biologically Based Mental Illness	Outpatient: $50 copay Inpatient: 70% subject to deductible	Outpatient: 50% subject to deductible Inpatient: 50% subject to deductible	Outpatient: $50 copay Inpatient: 90% subject to deductible	Outpatient: 70% subject to deductible Inpatient: 70% subject to deductible
Non-Biologically Based Mental Illness and Substance Abuse	Outpatient: $50 copay; 20 visits per calendar year combined in-network and out-of-network Inpatient: 30 days per calendar year combined in-network and out-of-network	Outpatient: 50% subject to deductible; 20 visits per calendar year combined in-network and out-of-network Inpatient: 30 days per calendar year combined in-network and out-of-network	Outpatient: $50 copay; 20 visits per calendar year combined in-network and out-of-network Inpatient: 30 days per calendar year combined in-network and out-of-network	Outpatient: 70% subject to deductible; 20 visits per calendar year combined in-network and out-of-network Inpatient: 30 days per calendar year combined in-network and out-of-network
Alcohol Abuse	Outpatient: $50 copay; subject to preapproval Inpatient: 70% subject to deductible and preapproval	Outpatient: 50% subject to deductible and preapproval Inpatient: 50% subject to deductible and preapproval	Outpatient: $50 copay; subject to preapproval Inpatient: 90% subject to deductible and preapproval	Outpatient: 70% subject to deductible and preapproval Inpatient: 70% subject to deductible and preapproval
Inpatient Extended Care or Rehab Center	70% subject to deductible and preapproval; 120 days per calendar year combined in-network and out-of-network	50% subject to deductible and preapproval; 120 days per calendar year combined in-network and out-of-network	90% subject to deductible and preapproval; 120 days per calendar year combined in-network and out-of-network	70% subject to deductible and preapproval; 120 days per calendar year combined in-network and out-of-network
Home Health Care	70% subject to deductible and preapproval	50% subject to deductible and preapproval	90% subject to deductible and preapproval	70% subject to deductible and preapproval
Durable Medical Equipment	70% subject to deductible and preapproval	50% subject to deductible and preapproval	90% subject to deductible and preapproval	70% subject to deductible and preapproval
Physical, Occupational, Speech, and Cognitive Therapy	$50 copay; 30 visits per therapy; per calendar year combined in-network and out-of-network	50% subject to deductible; 30 visits per therapy; per calendar year combined in-network and out-of-network	$50 copay; 30 visits per therapy; per calendar year combined in-network and out-of-network	70% subject to deductible; 30 visits per therapy; per calendar year combined in-network and out-of-network
Spinal Manipulation	$50 copay; 30 visits per calendar year combined in-network and out-of-network	50% subject to deductible; 30 visits per calendar year combined in-network and out-of-network	$50 copay; 30 visits per calendar year combined in-network and out-of-network	70% subject to deductible; 30 visits per calendar year combined in-network and out-of-network
Blood/Blood Products	70% subject to deductible	50% subject to deductible	90% subject to deductible	70% subject to deductible
Ambulance	100%; no deductible	50% subject to deductible	100%; no deductible	70% subject to deductible
Prescription Drug	50% not subject to deductible; does not count towards maximum out-of-pocket	50% not subject to deductible; does not count towards maximum out-of-pocket	50% not subject to deductible; does not count towards maximum out-of-pocket	50% not subject to deductible; does not count towards maximum out-of-pocket
Lifetime Maximum	Unlimited	Unlimited	Unlimited	Unlimited

What’s not covered?

• services or supplies furnished in connection with any procedures to enhance fertility;
• completion of claim forms;
• cosmetic surgery, except as stated in this policy; complications of cosmetic surgery; drugs prescribed for cosmetic purposes;
• services related to custodial care or domiciliary care;
• dental care or treatment, including appliances and dental implants, except otherwise stated in the policy;
• dose-intensive chemotherapy, except as otherwise stated in this policy;
• experimental or investigational treatments, procedures, hospitalizations, drugs, biological products or medical devices, except as otherwise stated in this policy;
• extraction of teeth, except for bony impacted teeth;
• services and supplies, unless stated in this policy for exams to determine the need or change of eyeglasses, eyeglass lenses of any type, except initial replacements for the loss of a lens; or eye surgery for lasik surgery, myopia, hyperopia, or astigmatism;
• services or supplies related to hearing aids and hearing exams to determine the need for the hearing aids or the need to adjust them, except as stated in the newborn hearing screening provision;
• marriage, career or financial counseling, sex therapy or family therapy, except as otherwise stated in the policy;
• private-duty nursing, except as provided for under home health care;
• self-administered services such as: biofeedback, patient-controlled analgesia, related diagnostic testing, self-care and self-help training;
• sterilization reversal;
• surgery, sex hormones, and related medical, psychological and psychiatric services to change your sex; services and supplies arising from complications of sex transformation;
• transplants, unless otherwise listed in this policy;
• services or supplies which are not medically necessary and appropriate except as otherwise stated in this policy.

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

This summary represents only a partial listing of the benefits and exclusions of the PPO program described in this summary. If you purchase another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. This managed care plan may not cover all of your health care expenses. Read your benefit booklet carefully to determine which health care services are covered. If you need more information please call 1-800-877-9829.