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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 2025, 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. The overall rating for this plan is not yet available for 2025.
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 $30.40. 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 $10100.00 (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 $10100.00 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 has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies and a $8 copay at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. If you qualify for the low-income subsidy (LIS), you will pay $30.40. Check the plan's formulary for specific drug coverage details.
Additional Benefits
The AmeriHealth Medicare Enhanced (PPO) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a $300 copay for the first 4 days, and no copay for the remaining days, while outpatient services have copays from $30-$325 depending on the service. The plan also covers primary care with no copay, and specialist visits for as low as $5. Additional benefits include coverage for hearing, vision, and dental services. Hearing exams have a $5 copay, and prescription hearing aids have a copay between $499 and $799. Vision services include eye exams with a copay between $0 and $5, and a $200 combined annual maximum benefit for eyewear. Dental services include no copay for oral exams, x-rays, cleaning, and fluoride treatment.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For days 1-4, there is a $300 copay, and for days 5-90, there is no copay. Additional days for Inpatient Hospital-Acute have no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services and observation services have a $325 copay, ASC services have a $300 copay, individual and group substance abuse sessions have a $30 copay, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the AmeriHealth Medicare Enhanced (PPO) plan, but prior authorization is required. You will have a $40 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and air ambulance services have a $250 copay, while transportation services to a plan-approved health-related location have no copay for up to 12 one-way trips per year. Transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the AmeriHealth Medicare Enhanced (PPO) plan. Emergency Services has a $125 copay, Urgently Needed Services have a copay between $5 and $40, and Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $125 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
AmeriHealth Medicare Enhanced (PPO) covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $25 copay, physician specialist services with a $5 copay, mental health specialty services with a $30 copay, podiatry services with a $20 copay, other health care professional services with a $0-$5 copay, psychiatric services with a $30 copay, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a $0-$25 copay, and opioid treatment program services with a $5 copay. Routine chiropractic care and routine foot care are limited to 6 visits per year.
Preventive Services See details
Preventive Services are covered, including annual physical exams with no copay. Additional preventive services are covered, and some services such as Health Education, Medical Nutrition Therapy, Home-Based Palliative Care, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay. Other services such as In-Home Safety Assessment, Personal Emergency Response System (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 Benefit, 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
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Hearing exams have a $5 copay, and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids (all types) have a copay between $499 and $799, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $5. The plan also covers contact lenses and eyeglasses (lenses and frames), but does not cover eyeglass lenses, eyeglass frames, or upgrades. There is a combined maximum benefit of $200 per year for eyewear.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $5 copay, and other services such as oral exams with no copay, dental x-rays with no copay, prophylaxis (cleaning) with no copay, and fluoride treatment with no copay. Restorative services and endodontics are covered with 20% coinsurance, while prosthodontics (removable and fixed) and implant services have 40% coinsurance, and oral and maxillofacial surgery has 20-40% coinsurance. Orthodontic services are covered up to a $2,000 annual maximum, and maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the AmeriHealth Medicare Enhanced (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical equipment is covered under the AmeriHealth Medicare Enhanced (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Prosthetics/Medical Supplies and Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, lab services, and radiological services. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $275, Therapeutic Radiological Services have a copay of $60, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the AmeriHealth Medicare Enhanced (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is a copay for some services, but the specific amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the AmeriHealth Medicare Enhanced (PPO) plan, but require prior authorization. You will have no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered SNF stays, and non-Medicare-covered SNF stays, are not covered.
Other Services See details
The AmeriHealth Medicare Enhanced (PPO) plan covers acupuncture with a $20 copay for up to 6 treatments per year, and over-the-counter (OTC) items up to $100 every three months. Other services such as meal benefits, and home health services are not covered.
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