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Benefits at a Glance

AmeriHealth PPO


Benefits IHC $25/$50/70% IHC $30/$50/90%
Benefits at a Glance PDF
  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.