AmeriHealth PPO High Deductible Health Plans

In-Network Coinsurance Options

Select in-network coinsurance and calendar year out-of-pocket maximum amounts.¹

	HC1	HC2
Coinsurance	100%	80%
Out-of-Pocket Maximum (Adjusted annually) Includes deductible, coinsurance, and copayments - Single2 - Family2	$5,500 $11,000	$5,500 $11,000

The deductible and coinsurance amounts that you select apply to the following in-network services:

• Doctor's Office Visits
• Physical/Occupational Therapy (30 visits per calendar year*)
• Spinal Manipulations & Speech Therapy (20 visits each per calendar year*)
• Cardiac & Pulmonary Rehabilitation (36 sessions each per calendar year*)
• X-Ray/Radiology/Diagnostics**
• Injectable Medications**
• Outpatient Lab/Pathology
• Hospital Services** (Unlimited inpatient days)
• Outpatient Surgery**
• Skilled Nursing Facility** (120 days per calendar year)
• Emergency Room (Not waived if admitted)
• Outpatient Private Duty Nursing** (360 hours per calendar year*)
• Prosthetics & Durable Medical Equipment**
• Inpatient Lab/Pathology

The in-network services noted below are covered in full or with a copayment:

Preventive Visits (Pediatric & Adult)	$20 Copayment, No deductible
Routine Gyn/Pap (1 per calendar year)*	$20 Copayment, No deductible
Mammography	100%, No deductible
Pediatric Immunizations	100%, No deductible

¹ Out-of-pocket maximums represent the 2007 amounts. These amounts may be adjusted annually on January 1, to correspond with changes by the Treasury Department.
² Single deductible and out-of-pocket maximum apply when an individual is enrolled without dependents. Family deductible and out-of-pocket maximum apply when an individual and one or more dependents are enrolled. Prior to benefits being paid, the entire family deductible must be met.
* Combined in/out-of-network maximum
** Pre-authorization required.