benefits at a glance - 2015 - get health insurance plans ... · benefits at a glance - 2015...

Benefits at a Glance - 2015Individual and Family

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

32 amerihealthnj.com 888-879-5331

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 you’ll pay when you 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 Exam4,5

Pediatric Eyeglasses or Contact Lenses4,5

Generic 30 Day Supply5

Brand 30 Day Supply5

Non-Preferred Brand

30 Day Supply5

IHC Platinum EPO Local Value12 $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

IHC Platinum EPO Regional Preferred $15 / $30







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




IHC Platinum HMO Local Value12

$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




IHC Platinum HMO Regional Preferred $15 / $30




$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 copayno charge,

no deductibleno charge,

no deductible$10 copay $40 copay $60 copay

IHC Platinum POS Plus National Access $15 / $25 4




$250 copay$300 / day, up to 5 days

$100 copay $50 copay$300 / day, up to 5 days




Out of Network $3,000 / $6,000 $8,000 / $16,000 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

IHC Platinum POS Plus Regional Preferred $15 / $25










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

IHC Platinum POS Plus Local Value12 $15 / $25










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

PLATINUM Benefits at a Glance 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

IHC 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 copay20%,

after deductible$50 copay $50 copay $50 copay $50 copay




IHC Gold EPO Regional Preferred $30 / $50 4 In Network $1,000 / $2,000 $5,000 / $10,000 $30 copay $50 copay



no deductible20%, after deductible 20%, after deductible $100 copay $75 copay





IHC Gold EPO National Access $30 / $50 4 In Network $1,000 / $2,000 $5,000 / $10,000 $30 copay $50 copay








IHC Gold EPO HSA Local Value12 80% / 80% 4 In Network $1,300 / $2,600 $2,500 / $5,000 20%, after deductible 20%, after deductible


20%, after deductible 20%, after deductibleno charge,

after deductible20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible



$10 copay, after deductible



IHC Gold EPO HSA Regional Preferred 80% / 80%

In Network $1,300 / $2,600 $2,500 / $5,000 20%, after deductible 20%, after deductibleno charge,

no deductible20%, after deductible 20%, after deductible

no charge, after deductible

20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductibleno charge,


no deductible$10 copay,

after deductible$40 copay,


after deductible

IHC Gold HMO Local Value12 $15 / $30 4 In Network $2,000 / $4,000 $4,650 / $9,300 $15 copay $30 copay








IHC Gold HMO Regional Preferred $15 / $30









IHC Gold EPO Community Advantage7,14

$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 BENEFITS

IHC

IHC

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

IHC Silver HMO Local Value12

$50 / $754 In Network $2,500 / $5,000 $6,350 / $12,700 $50 copay $75 copay





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


no deductible50%, up to $125 max,



no deductible

IHC 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



50%, up to $125 max, no deductible



IHC Silver EPO HSA Local Value12

$50 / $754 In Network $1,800 / $3,600 $4,500 / $9,000







30%, after deductible$500 copay / day up to 5 days, after deductible



$500 copay / day up to 5 days, after

deductible







50%, up to $125 max, after deductible



IHC Silver EPO HSA Regional Preferred $50 / $75

In Network $1,800 / $3,600 $4,500 / $9,000$50 copay,


after deductibleno charge,




after deductible30%, after deductible

$500 copay / day up to 5 days, after deductible



$500 copay / day up to 5 days, after deductible





no charge,no deductible

no charge,no deductible




IHC Silver EPO HSA Tier 1 Advantage11,12 $50 / $75

4

Tier 1

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





after deductible10%, after deductible 10%, after deductible



10%, after deductible$75 copay,







after deductible50%, up to $125 max,


after deductible

Tier 2$50 copay,





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

deductible$75 copay,








after deductible

IHC Silver EPO Community Advantage7,14

$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,


no charge no deductible

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





IHC Silver EPO HSA Local Value12

90% / 90%In Network $2,000 / $4,000 $6,450 / $12,900 10%, after deductible




after deductible10%, 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






IHC Silver EPO HSA Regional Preferred 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 deductibleno charge,




after deductibwle$60 copay,

after deductible

IHC Silver POS Plus Local Value12

$40 / $50












no deductible650%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible


$85 copay 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible not covered not covered not covered not covered not covered

IHC Silver POS Plus Regional Preferred $40 / $50















IHC Silver POS Plus National Access $40 / $50

4















SILVER Benefits at a GlanceIHC 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

IHC Bronze EPO HSA Local Value12

50% / 50%4 In Network $2,500 / $5,000 $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

IHC Bronze EPO HSA Regional Preferred 50% / 50%

4 In Network $2,500 / $5,000 $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

IHC Bronze EPO HSA National Access 50% / 50%

4 In Network $2,500 / $5,000 $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

IHC Bronze EPO HSA Tier 1 Advantage11,12 $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










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










IHC Bronze EPO HSA Community Advantage7,14 $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 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 GlanceIHC 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

IHC Local Value Simple Saver12,13 4 In Network $6,600 / $13,200 $6,600 / $13,200$30 copay,

no deductible10




















IHC Regional Preferred Simple Saver13 4 In Network $6,600 / $13,200 $6,600 / $13,200$30 copay,

no deductible10




















CATASTROPHIC Benefits at a GlanceIHC INTEGRATED PEDIATRIC VISION INTEGRATED PRESCRIPTION DRUGMEDICAL BENEFITS MEDICAL BENEFITS


DENTAL15,16 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

FOOTNOTES:1 Emergency room copay waived if admitted.2 Members can utilize 30 visits per therapy 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 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 $30 copay, no deductible for the first 3 visits per calendar year, then remaining visits covered at 100%, after deductible.11 Tier 1 facility providers are an enhancement to your benefits. Tier 2 facility providers are AmeriHealth New Jersey Local Value network providers. 12 The Local Value network is not available in Hunterdon County. 13 Catastrophic plans are only available for qualified individuals.14 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.15 Healthy Chompers plans are underwritten and administered by United Concordia.16This is a summary of benefits and limitations and exclusions apply.

Important plan information

The 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, call 888-879-5331 for additional assistance.

2015 Dental Overview

The 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.

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

amerihealthnj.com

© 2014 AmeriHealth | 18190 | 2014 OctoberAmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.

benefits at a glance - 2015 - get health insurance plans ... · benefits at a glance - 2015...

Documents