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AmeriHealth Medicare Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for AmeriHealth Medicare Enhanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on AmeriHealth Medicare Enhanced (PPO) in 2026, please refer to our full plan details page.
AmeriHealth Medicare Enhanced (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 Enhanced (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 Enhanced (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 Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $36.00. 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 a $150.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $12000.00 (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 $12000.00 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 Enhanced (PPO) plan features a $150 annual drug deductible. For Tier 1 preferred generics and Tier 2 generics, members enjoy no copay when utilizing preferred pharmacies or standard mail order services. If you choose a standard pharmacy, Tier 1 copays range from $7 to $14, while Tier 2 copays range from $8 to $16 depending on the fill length. For brand-name and specialty medications, costs are based on coinsurance regardless of the pharmacy type you choose. Tier 3 preferred brands require a 25% coinsurance, and Tier 4 non-preferred drugs carry a 30% coinsurance. Tier 5 specialty drugs require a 31% coinsurance for all available supply lengths.
Additional Benefits
The AmeriHealth Medicare Enhanced (PPO) plan offers robust medical coverage with predictable costs, featuring no copay or coinsurance for primary care visits and preventive services. For specialized care, members pay a low $15 copay for specialist visits, while inpatient hospital stays require a $390 daily copay for the first six days and no copay thereafter. Outpatient surgical services, emergency care, and ambulance services are covered with fixed copays and no coinsurance, helping you manage out-of-pocket expenses. This plan also includes essential dental, vision, and hearing benefits with no deductibles and mostly no copays for routine preventive exams. Comprehensive dental services are covered up to $1,500 annually with 20% to 40% coinsurance, and eyewear is covered up to a $200 annual limit with no copay. Additionally, home health services require no copay, while durable medical equipment and dialysis services are covered with a standard 20% coinsurance and no copay.
Inpatient Hospital See details
AmeriHealth Medicare Enhanced (PPO) covers inpatient acute hospital stays with no coinsurance, a $390 daily copay for days 1 through 6, and no copay for days 7 and beyond, excluding upgrades and non-Medicare-covered stays. Inpatient psychiatric hospital stays are also covered with no coinsurance, featuring a $345 daily copay for days 1 through 6 and no copay for days 7 through 90, though additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
AmeriHealth Medicare Enhanced (PPO) covers outpatient services with no coinsurance, featuring a $415 copay for outpatient hospital services, a $390 copay per stay for observation services, and a $325 copay for ambulatory surgical center services. Outpatient substance abuse services require a $30 to $40 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
AmeriHealth Medicare Enhanced (PPO) covers partial hospitalization benefits with a $40 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
AmeriHealth Medicare Enhanced (PPO) covers ground and air ambulance services with a $250 copay and no coinsurance, although prior authorization is required. Transportation services to health-related locations are not covered.
Emergency Services See details
AmeriHealth Medicare Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance, and urgently needed services with a $5 to $40 copay and no coinsurance. Worldwide emergency and urgent services are partially covered with a $115 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
AmeriHealth Medicare Enhanced (PPO) offers primary care physician visits with no copay and no coinsurance, while specialist visits require a $15 copay and no coinsurance. Other benefits include physical therapy, mental health, and telehealth services with copays ranging from $0 to $40 and no coinsurance, while chiropractic services are partially covered with a $15 copay for routine care.
Preventive Services See details
AmeriHealth Medicare Enhanced (PPO) offers partially covered preventive services with no copay and no coinsurance for covered care, including annual physical exams and kidney disease education. However, sub-services such as In-Home Safety Assessments, Personal Emergency Response Systems (PERS), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefits, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
AmeriHealth Medicare Enhanced (PPO) covers hearing services with no deductible or coinsurance, including a $15 copay for Medicare-covered exams and no copay for routine annual exams and fitting evaluations. Prescription hearing aids are partially covered with a copay of $499 to $799 for up to two devices per year, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by AmeriHealth Medicare Enhanced (PPO), offering eye exams with a $0 to $15 copay, no deductible, and no coinsurance. Covered eyewear also features no copay, no deductible, and no coinsurance up to a $200 annual limit, but other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
AmeriHealth Medicare Enhanced (PPO) covers dental services, offering preventative care with no copay and no coinsurance, and Medicare-covered dental with a $15 copay and no coinsurance. Comprehensive dental services, such as restorative care, endodontics, periodontics, implants, and prosthodontics, are covered up to $1,500 annually with no copay and 20% to 40% coinsurance. Other diagnostic, other preventive, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
AmeriHealth Medicare Enhanced (PPO) covers Home Infusion bundled Services with no copay, subject to prior authorization. Medicare Part B chemotherapy and other drugs are covered with no copay and a 0% to 20% coinsurance, while Part B insulin is available with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered under the AmeriHealth Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
AmeriHealth Medicare Enhanced (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, subject to prior authorization. Diabetic equipment is also covered with no copay for therapeutic shoes and inserts, and between no coinsurance and 20% coinsurance for diabetic supplies, though manufacturer limitations apply.
Diagnostic and Radiological Services See details
AmeriHealth Medicare Enhanced (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Outpatient lab services and diagnostic procedures have no copay, while outpatient x-rays require a $25 copay and therapeutic radiological services have a copay starting at $70.
Home Health Services See details
AmeriHealth Medicare Enhanced (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
AmeriHealth Medicare Enhanced (PPO) partially covers cardiac rehabilitation services with no coinsurance, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and carry copays ranging from $20 to $40.
Skilled Nursing Facility (SNF) See details
AmeriHealth Medicare Enhanced (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered period are not covered.
Other Services See details
AmeriHealth Medicare Enhanced (PPO) partially covers other services, offering acupuncture with a $15.00 copay and no coinsurance for up to 6 treatments every year. Over-the-counter (OTC) items, meal benefits, and other supplemental services are not covered under this plan.
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