Out-of-Network Benefits
All AmeriHealth Direct POS Flex Deductible Programs options utilize the same cost-sharing schedule for out-of-network benefits.
| Out-of-Network Benefits | |
|---|---|
| Deductible Individual/Family | $5,000/$15,000 |
| Coinsurance | 50% of plan allowance |
| Out-of-Pocket Maximum Individual/Family* | $15,000/$45,000 |
| Overall Lifetime Maximum | $500,000 |
| Office Visits | |
| Doctor's Office Visits Primary and OB/GYN Care Specialist |
50% 50% |
| Physical/Occupational Therapy (30 visits per cal. year) |
50% |
| Spinal Manipulations and Speech Therapy (20 visits each per cal. year) |
50% |
| Cardiac and Pulmonary Rehabilitation (36 sessions each per cal. year) |
50% |
| X-Ray/Radiology/Diagnostics | 50% |
| Injectable Medications** | 50% |
| Lab/Pathology | 50% |
| Facility/Ancillary | |
| Hospital Inpatient** (70 days out-of-network) |
50% |
| Outpatient Surgery** | 50% |
| Skilled Nursing Facility** | 50% |
| Emergency Room (Not waived if admitted) |
covered at In-Network level |
| Outpatient Private Duty Nursing** (360 hours per cal. year) |
50% |
| Prosthetics and Durable Medical Equipment (DME)** (DME $2,500 maximum per cal. year) |
50% |
Coinsurance is based upon Plan allowance and reflects amount paid by the Plan.
* Only member coinsurance is applied to the out-of-pocket maximum.
** Pre-authorization required for certain services.