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AmeriHealth Medicare Ultimate (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for AmeriHealth Medicare Ultimate (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on AmeriHealth Medicare Ultimate (PPO) in 2025, please refer to our full plan details page.
AmeriHealth Medicare Ultimate (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 Ultimate (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 Ultimate (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 Ultimate (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. Additionally, this plan comes with a Part B Premium reduction of $124.00. You must continue to pay paying your reduced 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 $14000.00 (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 $14000.00 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 Ultimate (PPO) plan has a $150 deductible for prescription drugs. In the initial coverage phase, you'll pay different amounts depending on the drug tier and pharmacy. For tier 1 preferred generic drugs, you will have no copay at preferred mail order pharmacies. For tier 2 standard generic drugs, the coinsurance is 25%. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The AmeriHealth Medicare Ultimate (PPO) plan offers comprehensive coverage with a variety of benefits. This plan includes inpatient hospital stays with copays ranging from $0 to $370, and outpatient services with copays varying from $0 to $425. It also provides coverage for emergency services, primary care, preventive services, hearing, vision, and dental, often with no copay or with relatively low copays. Additional benefits include ambulance services, partial hospitalization, and home health services, with varying copays or coinsurance. The plan also covers home infusion, dialysis, and medical equipment. However, this plan does not cover certain services such as cardiac rehabilitation, additional days for skilled nursing facilities, and some other services like private duty nursing and personal care services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization required. For Inpatient Hospital-Acute, you'll pay a $370 copay for days 1-6 and no copay for days 7-90, and for Inpatient Hospital Psychiatric, you'll pay a $335 copay for days 1-6 and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services, including all outpatient hospital services, observation services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services and observation services have a $425 copay, ambulatory surgical center services have a $400 copay, and individual and group sessions for outpatient substance abuse have a minimum and maximum copay of $30. Outpatient blood services have no copay.
Partial Hospitalization See details
AmeriHealth Medicare Ultimate (PPO) covers partial hospitalization with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the AmeriHealth Medicare Ultimate (PPO) plan. Ground and Air Ambulance Services have a $320 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered under the AmeriHealth Medicare Ultimate (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, and Urgently Needed Services have a copay between $15 and $40, but there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
AmeriHealth Medicare Ultimate (PPO) covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services and physical therapy and speech-language pathology services with a $35 copay, physician specialist services with a $50 copay, and mental health and psychiatric services with a $30 copay for individual and group sessions. This plan also covers podiatry services with a $15 copay, other health care professional services with a copay between $0 and $50, additional telehealth benefits with a copay between $0 and $50, and opioid treatment program services with a $5 copay.
Preventive Services See details
Preventive services include annual physical exams with no copay, as well as additional preventive services, kidney disease education services, and other preventive services. Health Education, Medical Nutrition Therapy (MNT), Home-Based Palliative Care, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay. 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. Fitness Benefit has no copay. Enhanced Disease Management has no copay. Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) have no copay.
Hearing Services See details
The AmeriHealth Medicare Ultimate (PPO) plan covers hearing exams with a $50 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams with a copay of $0-$50, and eyewear with a combined maximum benefit of $200 per year, and the plan covers one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The AmeriHealth Medicare Ultimate (PPO) plan covers dental services, including oral exams, dental x-rays, cleaning, and fluoride treatments, with no copay for these services. Restorative services, endodontics, periodontics, prosthodontics, implant services, and fixed prosthodontics are covered with a coinsurance between 20% and 40%, while oral and maxillofacial surgery is covered with a coinsurance between 20% and 40%. Maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the AmeriHealth Medicare Ultimate (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment and Prosthetics/Medical Supplies, is covered under the AmeriHealth Medicare Ultimate (PPO) plan. Durable Medical Equipment has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance. Diabetic Equipment is covered, and Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the AmeriHealth Medicare Ultimate (PPO) plan. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $400, Therapeutic Radiological Services have a copay of $60, and Outpatient X-Ray Services have a $40 copay.
Home Health Services See details
Home Health Services are covered under the AmeriHealth Medicare Ultimate (PPO) plan with no copay and no coinsurance; however, additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the AmeriHealth Medicare Ultimate (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the AmeriHealth Medicare Ultimate (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The AmeriHealth Medicare Ultimate (PPO) plan covers acupuncture with a $15 copay for up to 6 treatments per year. Over-the-counter items, meal benefits, dual eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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