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Benefits Summary

AmeriHealth® HMO Plus

Benefits Option 1 Option 2 Option 3 Option 4 Option 5 Option 6
Deductible NONE NONE NONE NONE NONE NONE
Out-of-Pocket Maximum $5,000 Individual/$10,000 Family $5,000 Individual/$10,000 Family $5,000 Individual/$10,000 Family $5,000 Individual/$10,000 Family $5,000 Individual/$10,000 Family $5,000 Individual/$10,000 Family
Overall Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited
Office Visit (PCP) $15/visit $15/visit $20/visit $20/visit $30/visit $30/visit
Specialist Visit $30/visit $30/visit $40/visit $40/visit $50/visit $50/visit
Inpatient Hospital Care* 100% $200/day (up to 5 days) 100% $300/day (up to 5 days) 100% $400/day (up to 5 days)
Outpatient Rehabilitation Therapy $30/visit $30/visit $40/visit $40/visit $50/visit $50/visit
Outpatient X-Ray (no copay applicable when service performed in ER or office setting) $30 Routine
$60 Complex*		 $30 Routine
$60 Complex*		 $40 Routine
$80 Complex*		 $40 Routine
$80 Complex*		 $50 Routine
$100 Complex*		 $50 Routine
$100 Complex*
Lab 100% 100% 100% 100% 100% 100%
Preventive Care $15/visit $15/visit $20/visit $20/visit $30/visit $30/visit
Maternity Care $15/1st OB Visit
100% Hospital		 $15/1st OB Visit
$200/day Hospital (up to 5 days)		 $20/1st OB Visit
100% Hospital		 $20/1st OB Visit
$300/day Hospital (up to 5 days)		 $30/1st OB Visit
100% Hospital		 $30/1st OB Visit
$400/day Hospital (up to 5 days)
Emergency Care (copay not waived if admitted) $100 $100 $100 $100 $100 $100

* 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.