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Benefits Summary

AmeriHealth® HMO

Benefits AmeriHealth 5 AmeriHealth 15 AmeriHealth Select III
Deductible None None None
Out-of-Pocket Maximum $650/member $1000 Individual/$2000 Family $2000 Individual/$4000 Family
Overall Lifetime Maximum Unlimited Unlimited Unlimited
Office Visit (PCP) $5 $15 $20
Specialist Visit $5 $25 $25
Hospital Care**
(Inpatient/Outpatient)		 100% 100% $125/day
$625 maximum/inpt adm
$100 copay per outpt surgery
Outpatient Rehabilitation Therapy
(includes Physical, Speech, and Occupational Therapy)		 100% (up to 60 consecutive days/condition) 100% (up to 60 consecutive days/condition) $25/visit (up to 60 consecutive days/condition)*
X-ray 100% 100% $25 copay*
Lab 100% 100% 100%
Preventive Care $5 $15 $15
Routine Gyn $5 $25 $25
Maternity Care $5 (1st visit only)
100% thereafter		 $25 (1st visit only)
100% thereafter		 $25 (1st visit only)
100% thereafter
Emergency Care $35 (waived if admitted) $35 (waived if admitted) $50 (waived if admitted)

* This benefit plan applies copays to physical, occupational, and speech therapy visits, and X-rays.
** 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 215-241-3400.