benefits at a glance - 2015€¦ · 23/10/2014 · benefits at a glance - 2015 small business...

Benefits at a Glance - 2015Small Business

Choose the best plan for you and your business.Use this brochure to compare plans and cost-sharing.

32 amerihealthnj.com

Choose the best health plan for you

Choosing a health plan is a big decision. But the good news is, you don’t have to make it alone. We’re here to help you — whether it’s to explain the different types of plans or to help you figure out which one makes the most sense for you.

Everything you need to get started is here. With this booklet, you’ll be able to look at plans side by side, so you can see how much your employees pay when they receive covered services.

PLAN NAME4

Denotes On

Exchange

NetworkIndividual / Family

Deductible

Maximum Out of Pocket

Individual / FamilyPrimary Care Visits Specialist Visits

Preventive CareScreenings,

Immunizations

X-rays and Diagnostic Imaging

ImagingCT / PT scans, MRIs

LaboratoryOutpatient SurgeryAmbulatory Surgical

Inpatient Hospital Services

Emergency Room1Urgent Care

Services

Inpatient Treatment Mental / Behavioral Health, Substance Abuse Disorder

Outpatient Treatment

Mental / Behavioral Health, Substance Abuse Disorder

Physical and Occupational

Therapy30 visits / calendar

year2

Speech and Cognitive Therapy 30 visits / calendar

year2

Chiropractic Care 30 visits / calendar year

Pediatric Routine Eye Exam3,4

Covered once a calendar year

Pediatric Eyeglasses or Contact Lenses3,4

Covered once a calendar year

Generic 30 Day Supply5

Brand 30 Day Supply5

Non-Preferred Brand

30 Day Supply5

SEH Platinum EPO Local Value11 $15 / $30

In Network $0 $3,500 / $7,000 $15 copay $30 copayno charge,

no deductible$30 copay $60 copay

no charge, no deductible



$100 copay $75 copayno charge,

no deductible$30 copay $30 copay $30 copay $30 copay



$10 copay $40 copay $60 copay

SEH Platinum EPO Regional Preferred $15 / $30











SEH Platinum EPO National Access$15 / $30











SEH Platinum HMO Local Value11

$15 / $30In Network $0 $3,000 / $6,000 $15 copay $30 copay



no deductible$225 copay

$225 copay / day, up to 5 days

$75 copay $50 copay$225 copay / day,

up to 5 days$30 copay $30 copay $30 copay $30 copay




SEH Platinum HMO Regional Preferred $15 / $30




$225 copay$225 copay / day,

up to 5 days$75 copay $50 copay


$30 copay $30 copay $30 copay $30 copayno charge,

no deductibleno charge,

no deductible$10 copay $40 copay $60 copay

SEH Platinum POS Plus Local Value11 $10 / $25










Out of Network $3,000 / $6,000 $5,000 / $10,000 30%, after deductible 30%, after deductibleno charge,

no deductible630%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible $100 copay $50 copay 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered not covered

SEH Platinum POS Plus Regional Preferred$10 / $25












SEH Platinum POS Plus National Access $10 / $25

4












SEH Platinum POS Plus Local Value11 $15 / $30












SEH Platinum POS Plus Regional Preferred$15 / $30












SEH SEH Platinum POS Plus National Access$15 / $30












PLATINUM Benefits at a Glance INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITSSEH

All plans within this brochure reflect member cost-sharing.


PLAN NAME4

Denotes On

Exchange


Deductible




Immunizations






Services






year2


year2






Non-Preferred Brand

30 Day Supply5

SEH Gold EPO Local Value12 $30 / $50

In Network $1,000 / $2,000 $5,000 / $10,000 $30 copay $50 copayno charge,



20%, after deductible 20%, after deductible $100 copay $75 copay 20%, after deductible $50 copay $50 copay $50 copay $50 copayno charge,



SEH Gold EPO Regional Preferred $30 / $50

4 In Network $1,000 / $2,000 $5,000 / $10,000 $30 copay $50 copayno charge,






SEH Gold EPO National Access $30 / $50







SEH Gold HMO Local Value11 $25 / $50, Rx 50% / $125 max




$250 copay $500 copay / day,



$50 copay $50 copay $50 copay $50 copay no charge,


no deductible50%, up to $125 max 50%, up to $125 max 50%, up to $125 max

SEH Gold HMO Regional Preferred $25 / $50, Rx 50% / $125 max




$250 copay $500 copay / day,



$50 copay $50 copay $50 copay $50 copay no charge,



SEH Gold HMO Local Value11 $25 / $50, Rx 50%









no deductible50% 50% 50%

SEH Gold HMO Regional Preferred $25 / $50, Rx 50%









no deductible50% 50% 50%

SEH Gold HMO Local Value11

$30 / $60In Network $0 $6,350 / $12,700 $30 copay $60 copay





$100 copay $85 copay$500 copay / day,

up to 5 days$60 copay $60 copay $60 copay $60 copay



$7 copay 50%, up to $125 max 50%, up to $125 max

SEH Gold HMO Regional Preferred $30 / $60









no deductible$7 copay 50%, up to $125 max 50%, up to $125 max

SEH Gold POS Local Value11 $30 / $60









no deductible$7 copay 50%, up to $125 max $60 copay


no deductible30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 70%, after deductible $100 copay $75 copay 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered 50% up to $125 max

SEH Gold POS Regional Preferred $30 / $60









no deductible$7 copay 50%, up to $125 max 50%, up to $125 max



SEH Gold POS Plus Local Value11 $30 / $60





up to 5 days$100 copay,

after deductible$75 copay






no deductible630%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible

$100 copay, after deductible

$75 copay 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered not covered

SEH Gold POS Plus Regional Preferred $30 / $60














$75 copay 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered

SEH Gold POS Plus National Access $30 / $60














$75 copay 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible not covered not covered not covered not covered not covered

SEH Gold HMO Plus Local Value11 $30 / $50





no deductible6

no charge, no deductible6

50%, up to $125 max, no deductible



SEH Gold HMO Plus Regional Preferred $30 / $50






no deductible50%, up to $125 max,



no deductible

SEH Gold HMO Plus Local Value11 $25 / $50










SEH Gold HMO Plus Regional Preferred $25 / $50










SEH Gold HMO Local Value11 $15 / $30






o deductible$10 copay $40 copay $60 copay

SEH Gold HMO Regional Preferred $15 / $30







SEH Gold POS Plus Local Value11 $30 / $50











SEH Gold POS Plus Regional Preferred $30 / $50











SEH Gold POS Plus National Access $30 / $50

4










no deductible640%, after deductible 40%, after deductible 40%, after deductible 40%, after deductible 40%, after deductible $100 copay $75 copay 40%, after deductible 40%, after deductible 40%, after deductible 40%, after deductible 40%, after deductible



not covered not covered not covered

SEH Gold EPO Community Advantage7,12 $10 / $20

4

Tier 1

$500 / $1,0008 $4,250 / $8,5009







Tier 2 $50 copay $75 copayno charge,






GOLD Benefits at a Glance INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITSSEH


PLAN NAME4

Denotes On

Exchange


Deductible




Immunizations






Services






year2


year2






Non-Preferred Brand

30 Day Supply5

SEH Bronze EPO HSA Local Value11

50% / 50%4 In Network $2,350 / $4,700 $6,450 / $12,900 50%, after deductible 50%, after deductible


50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductibleno charge,


no deductible50%, after deductible 50%, after deductible 50%, after deductible

SEH Bronze EPO HSA Regional Preferred 50% / 50%

4 In Network $2,350 / $4,700 $6,450 / $12,900 50%, after deductible 50%, after deductibleno charge,

no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible



50%, after deductible 50%, after deductible 50%, after deductible

SEH Bronze EPO HSA National Access 50% / 50%

4 In Network $2,350 / $4,700 $6,450 / $12,900 50%, after deductible 50%, after deductibleno charge,

no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible



50%, after deductible 50%, after deductible 50%, after deductible

SEH Bronze EPO HSA Tier 1 Advantage10 $50 / $75

4

Tier 1

$2,500 / $5,0008 $6,450 / $12,9009




50%, after deductible 50%, after deductible 50%, after deductible 20%, after deductible 20%, after deductible 50%, after deductible$75 copay,

after deductible20%, after deductible







50%, up to $125 max, after deductible



Tier 2$50 copay,

after deductible$75 copay,

after deductibleno charge,

no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible










SEH Bronze EPO HSA Community Advantage7,12 $25 / $50

4

Tier 1

$2,500 / $5,0008 $6,450 / $12,9009




50%, after deductible 50%, after deductible 50%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible$50 copay,







after deductible50%, up to $125 max,


after deductible

Tier 2$50 copay,



no deductible50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible










BRONZE Benefits at a GlanceSEH INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS

PLAN NAME4

Denotes On

Exchange


Deductible




Immunizations






Services






year2


year2






Non-Preferred Brand

30 Day Supply5

SEH Silver POS Plus Local Value11

$50 / $75











SEH Silver POS Plus Regional Preferred $50 / $75











SEH Silver POS Plus National Access$50 / $75











SEH Silver HMO Local Value11 $50 / $75




50%, after deductible 50%, after deductible$100 copay,

after deductible$85 copay 50%, after deductible $75 copay $75 copay $75 copay $75 copay






SEH Silver HMO Regional Preferred $50 / $75




50%, after deductible 50%, after deductible$100 copay,

after deductible$85 copay 50%, after deductible $75 copay $75 copay $75 copay $75 copay






SEH Silver EPO HSA Tier 1 Advantage10

$50 / $754

Tier 1

$1,350 / $2,7008 $5,750 / $11,5009




50%, after deductible 50%, after deductibleno charge,

after deductible10%, after deductible 10%, after deductible



10%, after deductible$75 copay,


after deductible $75 copay,


after deductible no charge,


no deductible$7 copay,



after deductible

Tier 2$50 copay,



no deductible50%, after deductible 50%, after deductible

no charge, after deductible

50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible$75 copay,









after deductible

SEH Silver EPO Community Advantage7,12

$15 / $354

Tier 1

$2,000 / $4,0008 $6,350 / $12,7009




20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible $35 copay $35 copay $35 copay $35 copayno charge,





Tier 2 $50 copay $75 copayno charge,



50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible $75 copay $75 copay $75 copay $75 copayno charge,





SEH Silver EPO HSA Local Value11 90% / 90%

In Network $2,000 / $4,000 $6,450 / $12,900 10%, after deductible 10%, after deductibleno charge,



10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible 10%, after deductible no charge,


no deductible $10 copay,



after deductible

SEH Silver EPO HSA Regional Preferred90% / 90%









after deductible

SEH Silver EPO HSA National Access 90% / 90%









after deductible

SEH Silver EPO HSA Local Value11 100% / 100%

4 In Network $2,000 / $4,000 $6,450 / $12,900no charge,




















after deductible

SEH Silver EPO HSA Regional Preferred100% / 100%

In Network $2,000 / $4,000 $6,450 / $12,900no charge,




















after deductible

SEH Silver EPO HSA National Access100% / 100%

In Network $2,000 / $4,000 $6,450 / $12,900no charge,




















after deductible

SILVER Benefits at a GlanceSEH INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS

DENTAL13,14 Healthy Chompers Child Healthy Chompers Child with Adult Preventive

Child Ages 0-18 (benefits through end of contract year in which

child reaches age 19)

Child Ages 0-18 (benefits through end of contract year in which

child reaches age 19)

Adult

Age 19+

Deductible $350 per child $350 per child $0

Annual MaximumIn-network: None

Out-of-network: $1,000In-network: None

Out-of-network: $1,000$1,000

Out of Pocket Maximum$350 for 1 child

$700 for 2+ children$350 for 1 child

$700 for 2+ childrenN / A

Preventive and Diagnostic• 90% exams and cleanings, not subject to deductible• 50% x-rays and flouride, not subject to deductible• 50% sealants and space maintainers, after deductible

• 90% exams and cleanings, not subject to deductible• 50% x-rays and flouride, not subject to deductible• 50% sealants and space maintainers, after deductible

100% exams, cleanings, and x-rays

Basic 50%, after deductible 50%, after deductible• Not covered• Discounts available from network dentists – 36%

average discount

Major 50%, after deductible 50%, after deductible• Not covered• Discounts available from network dentists – 36%

average discount

Medically Necessary Orthodontia 50%, after deductible 50%, after deductible N / A

259 Prospect Plains Road, Bldg. M, Cranbury, NJ 08512-3706

amerihealthnj.com

© 2014 AmeriHealth | 18191 | 2014 OctoberAmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.

Important plan informationThe benefits summaries in this brochure represent only a partial listing of benefits of the plans. Benefits and exclusions may be further defined by medical policy. These managed care plans may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you need more information, please contact your broker.

2015 Dental OverviewThe Patient Protection and Affordable Care Act (PPACA) requires that all members have pediatric dental essential health benefits. By choosing one of the following dental plans, you will meet this requirement. If you do not select one of these plans, proof that you have pediatric dental coverage under another plan will be required.

FOOTNOTES:1 Emergency room copay waived if admitted.2 Members can utilize 30 visits combined per calendar year.3 Available for members up to age 19, covered once per calendar year.4 Davis Vision administers the pediatric vision program. For frames to be covered in full, choose from Davis Vision’s Pediatric frame selection. 5 Prescription mail order benefit is available at 2x applicable cost-sharing for a 90 day supply.6 No charge, no deductible for up to $750 per child up to 1 year of age and $500 per covered person maximum over the age of 1.7 Community Advantage plans are only available to individuals and small employers based in Atlantic, Burlington, Camden, Cape May, and Gloucester Counties.8 Deductible is combined for Tier 1 and Tier 2.9 Out-of-pocket maximum is combined for Tier 1 and Tier 2. 10 Tier 1 facility providers are an enhancement to your benefits. Tier 2 facility providers are AmeriHealth New Jersey Local Value network providers. 11 The Local Value network is not available in Hunterdon County. 12 Tier 1 professional and facility providers are an enhancement to your benefits. Tier 2 professional and facility providers are AmeriHealth New Jersey Local Value network providers.13 Healthy Chompers plans are underwritten and administered by United Concordia.14 This is a summary of benefits and limitations and exclusions apply.

benefits at a glance - 2015€¦ · 23/10/2014 · benefits at a glance - 2015 small business...

Documents