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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 2026, 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. This plan received an overall rating of 2.5 out of 5 stars in 2026.
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 $95.00. 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 $125.00 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 $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 Ultimate (PPO) plan features a low $125 annual drug deductible for prescription coverage. For Tier 1 preferred generics and Tier 2 generics, members pay no copay when filling prescriptions at a preferred pharmacy or through standard mail order. Standard pharmacy fills for these tiers require a copay, starting at $9 for Tier 1 and $20 for Tier 2 for a one-month supply. For higher-tier medications, costs are structured as a percentage of the drug cost rather than flat copays. Tier 3 preferred brands require a 25% coinsurance, Tier 4 non-preferred drugs carry a 30% coinsurance, and Tier 5 specialty drugs have a 31% coinsurance across all pharmacy options. This plan offers clear cost-sharing phases to help Medicare beneficiaries manage their annual healthcare expenses.
Additional Benefits
The AmeriHealth Medicare Ultimate (PPO) plan offers comprehensive coverage with many services requiring no copay and no coinsurance. Beneficiaries enjoy no copay for primary care visits, routine preventive care, home health services, and diagnostic laboratory tests. For inpatient hospital stays, there is no coinsurance and a $400 copay for days 1 to 6 of acute care, while outpatient hospital services require a $550 copay. Specialist visits and Medicare-covered dental services require a $55 copay, whereas routine dental and vision exams are available with no copay. Covered prescription hearing aids carry a copay of $699 to $999, while durable medical equipment and dialysis services require no copay and a 20% coinsurance. Emergency care is also covered with a $115 copay and no coinsurance.
Inpatient Hospital See details
AmeriHealth Medicare Ultimate (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a copay of $400 for days 1 to 6 of acute stays and $345 for days 1 to 6 of psychiatric stays, with no copay for subsequent days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
AmeriHealth Medicare Ultimate (PPO) covers outpatient services with no coinsurance, featuring a $550 copay for outpatient hospital services, a $400 copay per stay for observation services, and a $425 copay for ambulatory surgical center services. Outpatient substance abuse services have a $30 to $40 copay with no coinsurance, and outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
AmeriHealth Medicare Ultimate (PPO) covers partial hospitalization services with a $40.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
AmeriHealth Medicare Ultimate (PPO) covers ground and air ambulance services with a $310 copay and no coinsurance, though prior authorization is required. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services are covered by the AmeriHealth Medicare Ultimate (PPO) with a $115 copay and no coinsurance, while urgently needed services require a $15 to $40 copay and no coinsurance. Worldwide emergency and urgent care are partially covered with a $115 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
AmeriHealth Medicare Ultimate (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Other services such as occupational and physical therapy have a $35 copay, and routine chiropractic and podiatry visits have a $15 copay with no coinsurance, though other chiropractic services are not covered.
Preventive Services See details
AmeriHealth Medicare Ultimate (PPO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management. However, additional preventive services are only partially covered, excluding in-home safety assessments, personal emergency response systems, weight management, alternative therapies, therapeutic massage, adult day health, and counseling.
Hearing Services See details
Hearing services are partially covered by AmeriHealth Medicare Ultimate (PPO), excluding OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids. Medicare-covered exams require a $55 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance, and covered prescription hearing aids cost a $699 to $999 copay and no coinsurance.
Vision Services See details
Vision services are partially covered by AmeriHealth Medicare Ultimate (PPO) with no deductibles and no coinsurance, featuring a $0 to $55 copay for eye exams and no copay for eyewear up to a $200 annual limit. One routine eye exam and one pair of eyeglasses or contact lenses are covered per year, while other eye exams, individual lenses, individual frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by AmeriHealth Medicare Ultimate (PPO), excluding other diagnostic services, other preventive services, maxillofacial prosthetics, and orthodontics. Medicare-covered dental has a $55 copay and no coinsurance, preventive care has no copay and no coinsurance, and comprehensive services require no copay and 20% to 40% coinsurance up to a $500 annual maximum.
Home Infusion bundled Services See details
Home infusion bundled services are covered by AmeriHealth Medicare Ultimate (PPO) with no copay, while Medicare Part B insulin drugs have a $35 copay and no coinsurance. Other covered Part B drugs, including chemotherapy and radiation, require no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the AmeriHealth Medicare Ultimate (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
AmeriHealth Medicare Ultimate (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance. Diabetic supplies are covered with a coinsurance ranging from no coinsurance to 20%, while diabetic therapeutic shoes and inserts feature no copay, with prior authorization required for these services.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by AmeriHealth Medicare Ultimate (PPO) with no coinsurance, though prior authorization is required. Diagnostic procedures, tests, and lab services have no copay, while outpatient X-rays require a $45 copay, therapeutic radiological services have a minimum copay of $85, and diagnostic radiological services have a minimum copay of $0.
Home Health Services See details
Home Health Services are covered under the AmeriHealth Medicare Ultimate (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
AmeriHealth Medicare Ultimate (PPO) covers Cardiac Rehabilitation Services with no coinsurance, though some services are not covered, including standard cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($25 copay), and supervised exercise therapy for peripheral artery disease ($20 copay).
Skilled Nursing Facility (SNF) See details
AmeriHealth Medicare Ultimate (PPO) covers skilled nursing facility services with no coinsurance, requiring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
AmeriHealth Medicare Ultimate (PPO) offers partial coverage for other services, which includes acupuncture for a $15.00 copay and no coinsurance for up to 6 treatments per year. Over-the-counter (OTC) items, meal benefits, and other supplemental services are not covered under this plan.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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