IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75

91762NJ0070004
Expanded Bronze
EPO

IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 is an Expanded Bronze EPO plan by AmeriHealth New Jersey.

Locations

IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 91762NJ0070004.
Insurer: AmeriHealth New Jersey
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: Yes
Plan ID: 91762NJ0070004

Cost-Sharing Overview

IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, Pregnancy, High Blood Pressure & High Cholesterol
Notice Pregnancy: Yes
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Care is covered outside of the service area.
National Network: No

Additional Benefits and Cost-Sharing

IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Lenses and Hardware or Contacts are covered once per calendar year for dependents age 19 and younger. Limit includes 1 pair of standard frames from the select Davis Vision collection. There is a $150 allowance for non-collection frames.
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Coverage for Physical Therapy and Occupational Therapy, is limited to 30 visits each per calendar year; coverage of cognitive rehabilitation therapy and speech therapy, is limited to 30 visits each per calendar year.
Dental Check-Up for Children
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The policy covers non-surgical care and treatment which includes diagnostic services. Allergy testing is covered as a diagnostic service.Additional EHB Benefit
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The policy also covers treatment of an Injury to natural teeth or the jaw, but only if: a) the Injury was not caused, directly or indirectly by biting or chewing; and b) all treatment is finished within 6 months of the later of the date of the Injury or the effective date of the coverage. Treatment includes replacing natural teeth lost due to such Injury.
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year 30 visits each for Speech and Cognitive therapy.Additional EHB Benefit
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Referred to as therapeutic manipulation. 30 visits per calendar year.
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Cosmetic Surgery is excluded unless it is required as a result of an illness or injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly
Basic Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No A copay is required for up to 5 days.
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The policy provides coverage for medically necessary and appropriate surgery. Abortion is surgery and to the extent it is medically necessary and appropriate for the patient, is covered.Not EHB
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year 30 visits each for Physical and Occupational therapy.Substantially Equal
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Subject to pre-approval, the policy covers charges for nutritional counseling for the management of disease entities which have a specific diagnostic criteria that can be verified. The nutritional counseling must be prescribed by a Practitioner, and provided by a Practitioner. Cost share may vary depending on place of service or network status of provider.
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The policy covers reconstructive breast Surgery, Surgery to restore and achieve symmetry between the two breasts and the cost of prostheses following a mastectomy on one breast or both breasts. (See Inpatient Hospital Services for other limits/conditions. Inpatient Hospital Physician/Surgical cost are included in the fee for the surgery))
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year As required by MHPAEA, the 30 visit limit does not apply to speech, physical and occupational therapies covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities. Coverage for Physical Therapy and Occupational Therapy, is limited to 30 visits each per calendar year; coverage of cognitive rehabilitation therapy and speech therapy, is limited to 30 visits each per calendar year.Substantially Equal
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Pre-approval required. Covers medically necessary and appropriate services in a written home health plan when certified as needed to avoid continuing hospitalization or confinement in a SNF. Services and supplies must be included in the written plan and furnished by a home health agency through recognized health care professionals. The covered person’s practitioner must establish the written plan within 14 days after home health care starts and review it at least once every 60 days. Visit limitations for Home Health Care do not apply to NJ Individual Plans.Other Law/Regulation
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No See Inpatient Hospital Services for other limits/conditions.
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Under preventive care.Additional EHB Benefit
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The policy provides coverage for medically necessary and appropriate surgery. Bariatric surgery is surgery and to the extent it is medically necessary and appropriate for the patient, is covered. (See Inpatient Hospital Services for other limits/conditions. Inpatient Hospital Physician/Surgical cost are included in the fee for the surgery)
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Subject to pre-approval, the administration of antibiotic, nutrients, or other therapeutic agents by direct infusion.
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No If the donor does not have health coverage that would cover the costs associated with his or her role as donor, this Policy will cover the donor’s medical costs associated with the donation. (See Inpatient Hospital Services for other limits/conditions. Inpatient Hospital Physician/Surgical cost are included in the fee for the surgery))
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No A copay is required for up to 5 days.
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Pre-authorization or Pre-Approval are not required for the first 180 days of inpatient and/or outpatient treatment during each Calendar Year but may be required for inpatient treatment for the balance of the Calendar Year.
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Subject to pre-approval, the policy covers charges for procedures and Prescription Drugs to enhance fertility, except where specifically excluded in this Policy. The policy covers charges for: artificial insemination; and standard dosages, lengths of treatment and cycles of therapy of Prescription Drugs used to stimulate ovulation for artificial insemination or for unassisted conception.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Cost share may vary depending on place of service or network status of provider.
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Acupuncture
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Only covered when used as a substitute for other forms of anesthesia
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The policy covers charges for the Medically Necessary and Appropriate surgical and non-surgical treatment of TMJ in a Covered Person.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Age and frequency schedules may apply.Other Law/Regulation
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Referred to as Extended Care Center. A copay is required for up to 5 days.
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per 2 Years One hearing-impaired ear every 24-months. Covered for members 15 years old and younger. The hearing aid must be recommended or prescribed by a licensed physician or audiologist.Other Law/Regulation
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Private-Duty Nursing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The policy only covers charges by a Nurse for Medically Necessary and Appropriate private duty nursing care if such care is authorized as part of a written home health care plan, coordinated by a Home Health Agency, and covered under the Home Health Care Charges section.Other Law/Regulation
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Pre-authorization or Pre-Approval are not required for the first 180 days of inpatient and/or outpatient treatment during each Calendar Year but may be required for inpatient treatment for the balance of the Calendar Year. A copay is required for up to 5 days.
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Year Covers 1 exam per calendar year for dependents age 19 and younger.
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No

Free Preventive Services

There is no copayment or coinsurance for any of the following IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for IHC Bronze EPO HSA AmeriHealth Hospital Advantage $50/$75?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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