14/7/25, 10:30 Health Plan Details - Get Covered New Jersey

New Jersey's Official Health Insurance Marketplace

Plan Details
EXPENSE ESTIMATE LOW ($)
PLAN HIGHLIGHTS
 MARKETPLACE PLAN
IHC Silver EPO AmeriHealth Hospital
Plan Name
Advantage $10/$20
Office Visits $10
Generic Drugs $7
IHC Silver EPO AmeriHeal...
Deductible $50
SILVER EPO CSR ELIGIBLE
OOP Max $900

$4.80 /month HSA-compatible No

after $401.00 savings PROVIDER Search

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DOCTORS AND FACILITIES

Check for your doctor

 Deductible & Out-of-Pocket

In Network* Out-of-Network*

Deductible $50 (Individual) Not Available

Out-of-pocket max * $900 (Individual) Not Available

 Doctor Visit

In Network* Out-of-Network* Additional Information

Primary Care Visit * $10 Copay after deductible 100% Coinsurance

Specialist Visit * $20 Copay after deductible 100% Coinsurance

Benefit Explanation
Cost share may vary depending on place of
service or network status of provider.
Other Practitioner Office Visit (Nurse,
$10 Copay after deductible 100% Coinsurance Limits & Exclusions
Physician Assistant) *
Care and/or treatment by a Christian
Science practitioner or care by a family
member
Benefit Explanation
Age and frequency schedules may apply.
Preventive Limits & Exclusions
No Charge 100% Coinsurance
Care/Screening/Immunization * Routine immunizations for the sole
purpose of travel or as a requirement for a
member's employment.

 Tests

In Network* Out-of-Network* Additional Information

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Laboratory Outpatient and Professional

No Charge after deductible 100% Coinsurance
Services

X-rays and Diagnostic Imaging 50% Coinsurance after deductible 100% Coinsurance

Imaging (CT/PET scans, MRIs) 50% Coinsurance after deductible 100% Coinsurance

 Drugs

In Network* Out-of-Network* Additional Information

Limits & Exclusions

Generic Drugs * $7 Copay after deductible 100% Coinsurance Drugs prescribed for cosmetic purposes;
non-prescription drugs.
Limits & Exclusions
Preferred Brand Drugs 50% Coinsurance after deductible 100% Coinsurance Drugs prescribed for cosmetic purposes;
non-prescription drugs.
Limits & Exclusions
Non-Preferred Brand Drugs 50% Coinsurance after deductible 100% Coinsurance Drugs prescribed for cosmetic purposes;
non-prescription drugs.
Limits & Exclusions
Specialty drugs 50% Coinsurance after deductible 100% Coinsurance Drugs prescribed for cosmetic purposes;
non-prescription drugs.

 Outpatient

In Network* Out-of-Network* Additional Information

Outpatient Facility Fee 10% Coinsurance after deductible 100% Coinsurance

Limits & Exclusions

Outpatient Surgery Physician/Surgical
10% Coinsurance after deductible 100% Coinsurance Local anesthesia billed separately when
Services
charges are included in surgery fee.

 ER & Urgent Care

In Network* Out-of-Network* Additional Information

Benefit Explanation
Emergency Room Services $50 Copay after deductible 50% Coinsurance after deductible
Copay waived if admitted w/in 24 hours
Limits & Exclusions
Chartered flights. Travel or communication
expenses of patients, health care providers
or family members. Services for ambulance
Emergency Transportation/Ambulance 50% Coinsurance after deductible 50% Coinsurance after deductible
transport from a hospital to another
facility except when a member is
transferred to another inpatient health
care facility.

Urgent Care $40 Copay after deductible $40 Copay after deductible

 Hospital

In Network* Out-of-Network* Additional Information

Inpatient Hospital Services * 10% Coinsurance after deductible 100% Coinsurance

Limits & Exclusions

Inpatient Physician and Surgical Local anesthesia charges if billed
10% Coinsurance after deductible 100% Coinsurance
Services separately when charges are included in
the fee for the surgery.

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14/7/25, 10:30 Health Plan Details - Get Covered New Jersey

 Mental / Behavioral Health

In Network* Out-of-Network* Additional Information

Mental/Behavioral Health Outpatient Limits & Exclusions

$20 Copay after deductible 100% Coinsurance
Services Custodial care, education and training.

Mental/Behavioral Health Inpatient

10% Coinsurance after deductible 100% Coinsurance
Services
Benefit Explanation
Pre-authorization or Pre-Approval are not
required for the first 180 days of inpatient
and/or outpatient treatment during each
Substance Abuse Disorder Outpatient
$20 Copay after deductible 100% Coinsurance Calendar Year but may be required for
Services
inpatient treatment for the balance of the
Calendar Year.
Limits & Exclusions
Custodial care, education and training.
Benefit Explanation
Pre-authorization or Pre-Approval are not
required for the first 180 days of inpatient
Substance Abuse Disorder Inpatient
10% Coinsurance after deductible 100% Coinsurance and/or outpatient treatment during each
Services
Calendar Year but may be required for
inpatient treatment for the balance of the
Calendar Year.

 Pregnancy

In Network* Out-of-Network* Additional Information

Prenatal and postnatal care No Charge 100% Coinsurance

Delivery and All Inpatient Services for

10% Coinsurance after deductible 100% Coinsurance
Maternity Care

 Other Special Needs

In Network* Out-of-Network* Additional Information

Benefit Explanation
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
Home Healthcare Services 50% Coinsurance after deductible 100% Coinsurance
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.
Limits & Exclusions
Services furnished to family members,
other than the patient. Services and
supplies not included in the home health
care plan.
Benefit Explanation
Coverage for Physical Therapy and
Occupational Therapy, is limited to 30
visits each per calendar year; coverage of
Outpatient Rehabilitation Services $20 Copay after deductible 100% Coinsurance cognitive rehabilitation therapy and
speech therapy, is limited to 30 visits each
per calendar year.
Limits & Exclusions
30 Visit(s) per Year

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14/7/25, 10:30 Health Plan Details - Get Covered New Jersey

Benefit Explanation
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
Habilitation Services $20 Copay after deductible 100% Coinsurance
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.
Limits & Exclusions
30 Visit(s) per Year
Benefit Explanation
Skilled Nursing Facility 50% Coinsurance after deductible 100% Coinsurance
Referred to as Extended Care Center.

Durable Medical Equipment 50% Coinsurance after deductible 100% Coinsurance

Hospice Services 50% Coinsurance after deductible 100% Coinsurance

Benefit Explanation
Care or treatment by means of
acupuncture is excluded
Acupuncture Not Covered Not Covered
except when used as a substitute for other
forms of
anesthesia.
Benefit Explanation
30 visits each for Speech and Cognitive
Rehabilitative Speech Therapy $20 Copay after deductible 100% Coinsurance therapy.
Limits & Exclusions
30 Visit(s) per Year
Benefit Explanation
30 visits each for Physical and
Rehabilitative Occupational and
$20 Copay after deductible 100% Coinsurance Occupational therapy.
Rehabilitative Physical Therapy
Limits & Exclusions
30 Visit(s) per Year
Benefit Explanation
Well Baby Visits and Care No Charge 100% Coinsurance
Under preventive care.
Benefit Explanation
The policy covers non-surgical care and
Allergy Testing $20 Copay after deductible 100% Coinsurance treatment which includes diagnostic
services. Allergy testing is covered as a
diagnostic service.

Diabetes Education $10 Copay after deductible 100% Coinsurance

Benefit Explanation
Subject to pre-approval, the policy covers
charges for nutritional counseling for the
management of disease entities which
Nutritional Counseling $20 Copay after deductible 100% Coinsurance
have a specific diagnostic criteria that can
be verified. The nutritional counseling
must be prescribed by a Practitioner, and
provided by a Practitioner.

 Children's Vision

In Network* Out-of-Network* Additional Information

Benefit Explanation
Covers 1 exam per calendar year for
dependents through the end of the month
Eye Exam for Children * No Charge 100% Coinsurance
in which he or she turns age 19.
Limits & Exclusions
1 Exam(s) per Year
Eye Glasses for Children * No Charge 100% Coinsurance Benefit Explanation
Coverage for 1 eyeglasses (lenses and
frames) or contact lenses per calendar year

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 14/7/25, 10:30 Health Plan Details - Get Covered New Jersey

for dependents through the end of the

month in which he or she turns age 19.
Limits & Exclusions
1 Item(s) per Year
Standard frames refers to frames that are
not designer frames such as Coach,
Burberry, Prada and other designers.

 Children's Dental

In Network* Out-of-Network* Additional Information

Basic Dental Care (Child) Not Covered Not Covered

Dental Check Up (Child) Not Covered Not Covered

Major Dental Care (Child) Not Covered Not Covered

Orthodontia (Child) Not Covered Not Covered

These are only estimates. Please complete an application through GetCoveredNJ to see your actual costs.

Explanation of terms used

Expense Estimate The estimate is based on your answers about how much you will use healthcare -
- in other words, how many times you will go to the doctor and how many
prescriptions you have. (If you did not answer the questions we will assume that
an average member of your household visits the doctor approximately 1-2 times
per year and has approximately 0-2 prescriptions per year.)
Plan Type The type of health plan you choose determines your in- and out-of-network
benefits. Common types include HMO, EPO, PPO, and POS.
HSA-compatible Health Savings Accounts (HSAs) are savings accounts available through some
high-deductible health plans as a way to save money for certain medical
expenses. The funds contributed to the account aren’t subject to federal income
tax at the time of deposit. Funds must be used to pay for qualified medical
expenses, such as prescription drugs. Unlike a Flexible Spending Account (FSA),
the funds in HSAs roll over year to year if you don’t spend them.
Out-of-pocket max The maximum amount you'll pay out-of-pocket for your bills before the insurance
company starts paying 100% of the costs.
Primary Care Visit Estimated co-pay or co-insurance to visit a health care office or facility where
services are provided by a physician, nurse practitioner or physician assistant to
treat an injury or illness.
Specialist Visit A physician specialist focuses on a specific area of medicine or a group of
patients to diagnose, manage, prevent or treat certain types of symptoms and
conditions. A non-physician specialist is a provider who has more training in a
specific area of health care.
Other Practitioner Office Office visits for services from other health care providers such as registered
Visit (Nurse, Physician dieticians or physical therapists.
Assistant)
Preventive Routine health care that includes screenings, check-ups and patient counseling
Care/Screening/Immuniz to prevent illnesses, disease or other health problems.
ation

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