Pick network cost-sharing for facility and ancillary care.
Facility/Ancillary |
F1 |
F2 |
F3 |
F4 |
 F5* |
|---|---|---|---|---|---|
| Hospital Services** | |||||
| (Unlimited inpatient days) | $0 | $100/day Max 5 days ($500) |
$150/day Max 5 days ($750) |
$250/day Max 5 days ($1,250) |
$400/day Max 5 days ($2,000) |
| Outpatient Surgery** | |||||
| $0 | $50 | $75 | $125 | $200 | |
| Skilled Nursing Facility** | |||||
| (120 days per cal. year***) (copay not waived if admitted from inpatient hospital stay) |
$0 | $50/day Max 5 days ($250) |
$75/day Max 5 days ($375) |
$125/day Max 5 days ($625) |
$200/day Max 5 days ($1,000) |
| Emergency Room | |||||
| (Copay not waived if admitted) | $100 | $100 | $100 | $100 | $125 |
| Outpatient Private Duty Nursing** | |||||
| (360 hours per cal. year***) | 90% | 90% | 85% | 85% | 80% |
| Prosthetics and Durable Medical Equipment** | |||||
| 70% | 70% | 50% | 50% | 50% | |
Coinsurance is based upon plan allowance and reflects amount paid by the plan.
* F5 can only be paired with C3 or C4.
** Preauthorization required for certain services.
*** For AmeriHealth POS and POS Direct, combined in/out-of-network maximum.