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AmeriHealth Medicare Core (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for AmeriHealth Medicare Core (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on AmeriHealth Medicare Core (PPO) in 2026, please refer to our full plan details page.
AmeriHealth Medicare Core (PPO) is a PPO plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in South Central New Jersey Area. This plan received an overall rating of 2.5 out of 5 stars in 2026.
It's important to know that AmeriHealth Medicare Core (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about AmeriHealth Medicare Core (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For AmeriHealth Medicare Core (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $13900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The AmeriHealth Medicare Core (PPO) plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately. For generic medications, you will pay no copay for Tier 1 preferred generics and Tier 2 generics when using a preferred pharmacy or standard mail order. If you choose a standard pharmacy, Tier 1 copays range from $9 to $18, while Tier 2 copays range from $20 to $40. For higher-tier medications, costs are structured as coinsurance rather than flat copays. Tier 3 preferred brands require a 25% coinsurance, Tier 4 non-preferred drugs require a 37% coinsurance, and Tier 5 specialty drugs carry a 33% coinsurance. These coinsurance rates remain the same whether you use a preferred pharmacy, standard pharmacy, or standard mail order service.
Additional Benefits
AmeriHealth Medicare Core (PPO) offers comprehensive medical coverage with no copay and no coinsurance for primary care visits and preventive services, while specialist visits require a $55 copay. Inpatient hospital stays feature a daily copay of $350 for the first six days of acute care, and outpatient hospital services carry a $520 copay, both with no coinsurance. Emergency care is accessible with a $115 copay, and urgent care visits range from a $10 to $40 copay. Routine dental, vision, and hearing exams are available with no copay, though prescription hearing aids require copays between $699 and $999, and comprehensive dental services carry a 20% to 40% coinsurance. Home health services and diagnostic labs are covered with no copay and no coinsurance, whereas durable medical equipment and dialysis services require a 20% coinsurance. This plan balances low-cost routine care with predictable copays and coinsurance for specialized medical treatments.
Inpatient Hospital See details
AmeriHealth Medicare Core (PPO) covers inpatient hospital services with no coinsurance, requiring a $350 daily copay for days 1 to 6 of acute stays and a $345 daily copay for days 1 to 6 of psychiatric stays, followed by no copay for remaining covered days. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and psychiatric stays beyond 90 days are not covered.
Outpatient Services See details
AmeriHealth Medicare Core (PPO) covers outpatient services with no coinsurance, featuring a $520 copay for outpatient hospital services, a $430 copay for ambulatory surgical center services, and a $350 copay per stay for observation services. Outpatient substance abuse services require a $40 copay for individual sessions and a $30 copay for group sessions with no coinsurance, while outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by AmeriHealth Medicare Core (PPO) with a $40.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
AmeriHealth Medicare Core (PPO) covers ground and air ambulance services with a $310 copay per service and no coinsurance, though prior authorization is required. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
AmeriHealth Medicare Core (PPO) covers emergency services with a $115 copay and no coinsurance, and urgently needed services with a $10 to $40 copay and no coinsurance. Worldwide emergency services are partially covered, offering emergency and urgent care for a $115 copay and no coinsurance, while worldwide emergency transportation is not covered.
Primary Care See details
AmeriHealth Medicare Core (PPO) primary care benefits feature primary care physician visits with no copay and no coinsurance, and specialist visits for a $55 copay and no coinsurance. Additional services like therapy, mental health, and telehealth have copays ranging from $0 to $55 with no coinsurance, though chiropractic care is only partially covered as other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by AmeriHealth Medicare Core (PPO) with no copay and no coinsurance for covered options like annual physicals, fitness benefits, and kidney disease education. However, the plan does not cover in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, in-home support, caregiver support, additional smoking cessation, telemonitoring, home safety devices, or counseling.
Hearing Services See details
AmeriHealth Medicare Core (PPO) covers hearing services with no coinsurance, featuring a $55 copay for Medicare-covered exams and no copay for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with a copay ranging from $699 to $999 for up to two devices per year, but OTC hearing aids and inner ear, outer ear, or over the ear prescription models are not covered.
Vision Services See details
AmeriHealth Medicare Core (PPO) offers partially covered vision services with no deductibles, featuring eye exams with a $0 to $55 copay and no coinsurance, including one routine exam per year with no copay. Eyewear is covered with no copay or coinsurance up to a $200 combined annual limit for one pair of eyeglasses or contact lenses, while other eye exams, individual lenses, individual frames, and upgrades are not covered.
Dental Services See details
AmeriHealth Medicare Core (PPO) offers partially covered dental services, with Medicare-covered dental requiring a $55 copay and no coinsurance, preventive care having no copay or coinsurance, and comprehensive services carrying no copay and 20% to 40% coinsurance. Maxillofacial prosthetics, orthodontics, other diagnostic dental, and other preventive dental services are not covered.
Home Infusion bundled Services See details
AmeriHealth Medicare Core (PPO) covers Home Infusion bundled Services with no copay and no coinsurance, though prior authorization is required. Under this plan, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs carry a 0% to 20% coinsurance and no copay.
Dialysis Services See details
Dialysis services are covered by AmeriHealth Medicare Core (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
AmeriHealth Medicare Core (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance, requiring prior authorization. Diabetic therapeutic shoes and inserts have no copay, while diabetic supplies are limited to specified manufacturers and carry no copay with no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
AmeriHealth Medicare Core (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Members pay no copay for lab services, diagnostic procedures, and diagnostic radiology, while outpatient X-rays have a $25 copay and therapeutic radiology services require a copay of at least $75.
Home Health Services See details
AmeriHealth Medicare Core (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
AmeriHealth Medicare Core (PPO) covers some Cardiac Rehabilitation Services with no coinsurance, but standard Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
AmeriHealth Medicare Core (PPO) covers skilled nursing facility (SNF) services with no coinsurance, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and additional days beyond the 100 Medicare-covered days are not covered.
Other Services See details
AmeriHealth Medicare Core (PPO) partially covers other services, offering acupuncture with a $15.00 copay and no coinsurance for up to 6 treatments per year. Over-the-counter (OTC) items, meal benefits, and dual-eligible SNP services are not covered.
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