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Benefits Summary

AmeriHealth® HMO

Benefits AmeriHealth 15 AmeriHealth 20 Premium Select AmeriHealth 30 Select
Deductible None NONE None
Out-of-Pocket Maximum* $1,000 Individual/$2,000 Family $1,000 Individual/$2,000 Family $1,500 Ind
$3,000 Fam
Overall Lifetime Maximum Unlimited Unlimited Unlimited
Office Visit (PCP) $15 $20 $30
Specialist Visit $25 $25 $35
Hospital Care** (Inpatient/Outpatient) 100% $250 copay/day
(up to $1000)		 $350/admission
Outpatient Rehabilitation Therapy (Includes Physical, Speech and Occupational Therapy) 100%
(up to 60 consecutive days/condition)		 $25 100%
(up to 60 consecutive days/condition)
X-ray 100% $25 100%
Lab 100% 100% 100%
Preventive Care $15 $20 $30
Routine Gyn $25 $25 $35
Maternity Care $25 (1st visit)
100% thereafter		 $25 (1st visit)
100% thereafter		 $35 (1st visit)
100% thereafter
Emergency Care $35
(waived if admitted)		 $75
(waived if admitted)		 $75
(waived if admitted)

* Copayments and coinsurance apply to out-of-pocket maximum

** Precertification Required

The above table illustrates some of the benefit programs available. This managed care plan may not cover all your health care expenses. This information has been extracted from and is subject to the terms and conditions of all applicable group contracts and member handbooks.

For more information on the terms, limitations, and exclusions of the benefit programs, please contact your independent broker or our Marketing Department at 1-866-681-7368.