OMNIA 4 with BlueCard PPO
Your benefit period is a calendar year. In other words, things like your deductible reset on January 1.
The OMNIA plans cover eligible expenses rendered by providers in Horizon’ Managed Care network. When you utilize participating providers, you generally only pay your copayment and any applicable in-network coinsurance or deductible. No benefits are available out-of-network, except in emergent situations.
Deductible (per Calendar Year)
The deductible is the amount you must pay each year for covered charges before benefits are paid by your plan.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Individual | $500 | $2,500 |
| Family | $1,000 | $5,000 |
Coinsurance
Coinsurance is the fixed amount you must pay after you’ve paid the deductible for each medical visit to a participating doctor or other health care provider, usually at the time of service.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Coinsurance | 90% | 60% |
Maximum Out-of-Pocket (MOOP)
The maximum out-of-pocket is the most you must pay for covered health care services during a plan year.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Individual | $2,500 | $4,500 |
| Family | $5,000 | $9,000 |
Tier 1 Ded/MOOP accumulates to Tier 2 Ded/MOOP but Tier 2 Ded/MOOP does not accumulate to Tier 1 Ded/MOOP. Once Tier 2 Ded/MOOP has been met, Tier 1 will also have been met.
Split Maximum Out of Pocket is Calendar Year. The deductible, coinsurance, and copayments apply to the Maximum Out of Pocket.
Benefit Period Maximum
The benefit period maximum for Tier 1 and Tier 2 is unlimited.
Lifetime Maximum
The lifetime maximum for Tier 1 and Tier 2 is unlimited.
Primary Care Physician (PCP) Selection
Primary Care Physician (PCP) selection is not required.
Primary Care Office Visit
A primary care physician is a family practitioner, internist, pediatrician, or nurse practitioner.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Primary Care Office Visit | 100% after $15 copay | 100% after $30 copay |
Specialist Office Visit
A referral is not required to visit a specialist.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Specialist Office Visit | 100% after $25 copay | 100% after $50 copay |
Maternity Visits
Copay applies to 1st visit only. Dependent children are ineligible for maternity/obstetrical benefits.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Maternity Visits | 100% after $25 copay | 100% after $50 copay |
Allergy Testing and Treatment
| OMNIA Tier 1 | OMNIA Tier 2 |
| 100% in office setting. Copay only applies to office visit if billed. |
100% in office setting. Copay only applies to office visit if billed. |
| 90% after deductible outpatient facility | 60% after deductible outpatient facility |
Preventive Care
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Routine Adult Physicals, GYN Exams, PAP, Mammograms, Prostate Cancer Screening, Colorectal Screening, Immunizations | 100% | 100% |
| Well Child Exams | 100% | 100% |
| Well Child Immunizations and Lead Screening | 100% | 100% |
Diagnostic Procedures
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Laboratory | 100% in office or LabCorp/Quest 90% after deductible in outpatient facility |
100% in office or LabCorp/Quest 60% after deductible outpatient facility |
| X-ray/Radiology Services/Imaging/Ultrasound | 100% in office 100% in outpatient facility |
100% in office 60% after deductible outpatient facility |
CT/CTA Scans, Pet Scans, MRIs/MRAs, Ultrasounds, Nuclear Medicine studies (including Nuclear Cardiology) require prior authorization for members in NJ and Horizon participating providers in contiguous counties in DE, NY and PA.
- The ordering physician should request the prior authorization by calling eviCore at 1-866-496-6200 and providing the necessary clinical information.
- Once the authorization number is received, the member may call eviCore at 1-866-969-1234 to schedule an appointment.
For members outside of the area listed above, prior authorization is not required, claims are processed at the Tier 2 benefit when rendered by a participating BlueCard PPO Provider.
Note: Managed Care members can call 1-866-969-1234 to obtain a confirmation number for non-Advanced Imaging diagnostic procedures. Confirmation numbers from eviCore replace the need for a paper referral.
Hospital Care
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient Admission (including maternity) | 90% after deductible | 60% after deductible |
| Room and Board | 90% after deductible | 60% after deductible |
| Pre-admission Testing | 90% after deductible | 60% after deductible |
| Surgery in Hospital | 90% after deductible | 60% after deductible |
| Inpatient Physician Services | 90% after deductible | 60% after deductible |
| Outpatient Department Services (Non-Surgical) | 90% after deductible | 60% after deductible |
Emergency Care
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Emergency Room | $100 facility copay then deductible then 90% | $100 facility copay then deductible then 60% |
| Payment at the in-network level across-the-board applies only to true Medical Emergencies & Accidental Injuries. | ||
| Ambulance | 100% after Tier 1 deductible | 100% after Tier 1 deductible |
Outpatient Surgery
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Hospital Outpatient Surgery | 90% after deductible | 60% after deductible |
| Surgery in an Ambulatory SurgiCenter | 90% after deductible | 60% after deductible |
Mental Health Services
Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient | 90% after deductible | 60% after deductible |
| Outpatient Department | 90% after deductible | 60% after deductible |
| Office setting | 100% after $25 copay | 100% after $50 copay |
Substance Abuse Services
Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient | 90% after deductible | 60% after deductible |
| Outpatient Department | 90% after deductible | 60% after deductible |
| Office setting | 100% after $25 copay | 100% after $50 copay |
Alcohol Abuse Services
Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient | 90% after deductible | 60% after deductible |
| Outpatient Department | 90% after deductible | 60% after deductible |
| Office setting | 100% after $25 copay | 100% after $50 copay |
Other Services
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Bariatric Surgery | 90% after deductible | 60% after deductible |
| Diabetic Education | 100% after office copayment | 100% after office copayment |
| Diabetic Supplies | 90% after deductible | 60% after deductible |
| Durable Medical Equipment | 90% after deductible | 60% after deductible |
| Orthotics and Prosthetics | 90% after deductible | 60% after deductible |
| Home Health Care | 100% after $15 copay | 100% after $30 copay |
| Hospice Care | 90% after deductible | 60% after deductible |
| Physical Rehabilitation Facility Inpatient Services | 90% after deductible | 60% after deductible |
| Short-term Therapies: Physical, Occupational, Speech, Respiratory | 100% after $15 copay 90% after deductible in outpatient facility 30 visit maximum per therapy, per benefit period |
100% after $30 copay 60% after deductible in outpatient facility 30 visit maximum per therapy, per benefit period |
| Private Duty Nursing | 90% after deductible Limited to 30 visits per benefit period (8-hour shifts) |
60% after deductible Limited to 30 visits per benefit period (8-hour shifts) |
| Skilled Nursing Facility/Extended Care Center | 90% after deductible Limited to 100 days per benefit period |
60% after deductible Limited to 100 days per benefit period |
| Therapeutic Manipulation (Chiropractic Care) | 100% after $25 copay 25 visit maximum per benefit period |
100% after $30 copay 25 visit maximum per benefit period |
| Adult Vision | Not Covered | Not Covered |
| Adult Vision Hardware | Not Covered | Not Covered |
| Pediatric Vision & Vision Hardware (child dependents under age 19) | Routine Pediatric Vision Covered 1/year and Hardware Services are covered up to $150 | Routine Pediatric Vision Covered 1/year and Hardware Services are covered up to $150 |
| Telemedicine Services | Not Covered | Not Covered |
Prescription Drugs
Covered under freestanding prescription program
Eligibility
Dependent children, including full-time students are covered until the end of the month in which they reach the age of 26. Handicapped dependents are covered beyond the child removal age, if the handicap occurred prior to the age of 26. Under certain conditions, coverage may be extended for qualified dependents up to age 31. Please refer to your benefit booklet for further information as this benefit highlight is not an exhaustive list.
Pre-Existing Conditions
Not Applicable
Prior Authorization
Some services/procedures require prior authorization. For a complete list, contact our customer service number at 1-800-355-BLUE (2583).
Please note that the benefit highlights are provided for informational purposes. Horizon BCBSNJ makes every effort to provide clear and accurate information pertaining to these benefit highlights. However, because Horizon BCBSNJ generally expects continued guidance from regulators on issues pertaining to Federal health care reform, the information that has been provided is subject to change. Horizon BCBSNJ will provide notice of such changes to members pursuant to State and Federal requirements.
This summary highlights the major features of your health benefit program. It is not a contract and some limitations and exclusions may apply. Payment of benefits is subject solely to the terms of the contract. Please refer to your benefit booklet for more information.
