| Service |
Network |
Non-Network |
| Deductible |
NONE |
$1,000 per person, two times per family |
| Hospital Precertification and Utilization Review is required for all hospital admissions. There is a 20% penalty, up to a maximum of $2,500.00, if you do not obtain precertification. |
| Hospital |
Medical Emergency/
Accidental Injury |
90% after $50 copay |
60% after deductible |
| |
Non-emergency Non-Network subject to $50 copay, Deductible and 60% coinsurance |
| Inpatient |
$250 Copay per day up to 5 days per admission, 2 admission max per year
90% covered |
$250 Copay per day up to 5 days per admission, 2 admission max per year
60% after deductible |
| Outpatient |
90% covered |
60% after deductible |
| Skilled Nursing Facility |
90% covered
(100 days max) |
60% after deductible
(60 days max) |
| Home Health Care (100 visits max) |
90% covered |
60% after deductible |
| Hospice ($9,000 max) |
90% covered |
60% after deductible |
| Physician Services |
| Surgery |
90% covered |
60% after deductible |
| Inpatient visit |
90% covered |
60% after deductible |
| Office visit |
$25 Copay |
60% after deductible |
| Specialist visit |
$40 Copay |
60% after deductible |
| Preventive Care |
|
Including immunizations; outpatient well baby care; and periodic health exams
|
$750 each year per covered dependent child through end of calendar year in which child attains age one;
$500 maximum per covered person per calendar year.
Not subject to deductible or coinsurance.
|
| Payment Limits per Calendar Year |
| Short Term Therapies |
90% covered |
60% after deductible |
Physical, Speech, Occupational,
Respiratory/Inhalation, Therapeutic Manipulation |
Combined Network/Non-Network:30 visits a year for each therapy |
| |
| Infertility (excludes in-vitro fertilization) |
$40 Copay |
60% after deductible |
| Network/Non-Network combined $5,000 lifetime max for employee and spouse |
| Service |
Network |
Non-Network |
| Mental Health/Substance Abuse |
| All Mental Health/Substance Abuse Care services must be coordinated through the Horizon
BCBSNJ/Magellan Behavioral Health Program. Biologically Based Mental Illnesses will be paid as any other medical
condition pursuant to the NJ State mandate. |
| Inpatient Services |
90% covered
45 days per benefit period/
90 days lifetime |
60% after deductible
30 days per benefit period/
90 days lifetime |
| Outpatient Services |
$40 Copay
50 visits per benefit period/
150 visits lifetime |
60% after deductible
20 visits per benefit period/
60 visits lifetime |
| Group Therapy |
$40 Copay
3 sessions = 1 visit |
No Benefit |
| Partial Hospitalization |
2 partial days = 1 inpatient day
45 days per benefit period |
No Benefit |
| Other services |
| Anesthesia |
90% covered |
60% after deductible |
Ambulance
(Ground transportation only) |
90% covered |
60% after deductible |
Durable medical equipment
(Combined $5,000 max.) |
90% covered |
60% after deductible |
| Lab and X-ray |
90% covered |
60% after deductible |
Private Duty Nursing
(30 visits) |
90% covered |
No Benefit |
| Nutrition |
$40 Copay
(3 visits year) |
No Benefit |
Routine Vision Exam
$50 hardware allowance in a 2 calendar year period |
$40 Copay |
60% after deductible |
| Prescription Drug Card: See Rx Options Description Summary |
NETWORK Payment for eligible expenses when services are obtained from one of the providers in the
Managed Care Network. Horizon BCBSNJ reimburses both Primary Care physicians and Specialists at the applicable allowance
on a fee-for-service basis. Direct Access provides the highest level of benefits for in-network services and the member does not have to file a claim.
NON-NETWORK Horizon BCBSNJ's payment for eligible services that are not obtained from one of the
providers in the Managed Care Network. The member may see any physician if he/she is willing to pay a greater share of
the costs. Horizon BCBSNJ reimburses participating providers at the applicable allowance. Non-network providers are
reimbursed up to our applicable allowance and may balance bill to charges. An annual deductible and a coinsurance apply
to all eligible medical and most supplemental services. Once the member reaches the coinsurance limit, the plan pays 100%
of the appropriate allowance for eligible services for the rest of the year. The member is responsible for complying with all
utilization review and cost containment.
ANNUAL DEDUCTIBLE Network: None Non-Network: $1,000 per person, two times per family.
COINSURANCE Maximum annual out-of-pocket after the deductible for eligible expenses: applicable
coinsurance limit to $10,000 per person/$25,000 per family, 100% thereafter.
|
