High Option PPO
You can save money when you choose to receive care from providers that participate in the Horizon BCBSNJ networks. When you use participating hospitals or other medical facilities or doctors, you generally only pay your copayment and any applicable in-network coinsurance or deductible. Generally, if you have services performed at an out of network facility or by an out of network provider, your out of network benefits will apply. This means that you will be responsible for amounts exceeding Horizon BCBSNJ's allowable reimbursement for that particular service and this may result in significant out of pocket costs. You will be responsible to pay for this amount directly to the non-participating hospital, ambulatory surgery center or provider. By using our Horizon-BCBSNJ network providers, you keep your health care costs down.
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 Benefits Enrollment Guide for more information.
Deductible (per Calendar Year)
The deductible is the amount you must pay each year for covered charges before benefits are paid by your plan.
| Benefit | In-Network | Out-of-Network |
| Employee | $350 | $700 |
| Employee + 1 | $700 | $1,400 |
| Family | $1,050 | $2,100 |
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.
| In-Network | Out-of-Network | |
| 90% | 70% |
Maximum Out-of-Pocket (MOOP)
The maximum out-of-pocket (MOOP) is the most you must pay for covered health care services during a calendar year. The coinsurance, copayments (excludes Rx copayments) and deductible apply to the Maximum Out of Pocket.
Balances from non-participating providers over our allowance are not eligible towards the Maximum Out of Pocket.
| Benefit | In-Network | Out-of-Network |
| Employee | $1,850 | $3,700 |
| Employee + 1 | $3,700 | $7,400 |
| Family | $5,500 | $11,100 |
The coinsurance, copayments (excludes Rx copayments) and deductible apply to the Maximum Out of Pocket.
Balances from non-participating providers over our allowance are not eligible towards the Maximum Out of Pocket.
Benefit Period Maximum
| Benefit | In-Network | Out-of-Network |
| Benefit Period Maximum | Unlimited | Unlimited |
Lifetime Maximum
| Benefit | In-Network | Out-of-Network |
| Lifetime Maximum | Unlimited | Unlimited |
Doctor’s Office Visits
| Benefit | In-Network | Out-of-Network |
| Primary Care* Office Visit | $20 Copayment | 70% after Deductible |
| Specialist Office Visit A referral is not required to visit a specialist. |
$30 Copayment: Physical Therapy and Chiropractic Care $40 Copayment: for all other specialists |
70% after Deductible |
| Maternity Visits | 90% after Deductible (initial visit covered at 100% after copay) |
70% after Deductible |
| Allergy Testing and Treatment | 100% Copay applies to office visit charge only |
70% after Deductible |
Preventive Care
| Benefit | In-Network | Out-of-Network |
| Routine Adult Physicals, GYN Exams, PAP, Mammograms, Prostate Cancer Screening, Colorectal Screening, Immunizations* | 100% | 60% after Deductible |
| Well Child Exams* | 100% | 60% after Deductible |
| Routine Laboratory, X-ray/ Radiology Services | 100% | 60% after Deductible |
Hospital Care
| Benefit | In-Network | Out-of-Network |
| Facility fee (e.g., hospital room) | 90% after Deductible | 70% after Deductible |
| Physician/surgeon fee | 90% after Deductible | 70% after Deductible |
Emergency Care
| Benefit | In-Network | Out-of-Network |
| Emergency Room | $100 Copayment* | $100 Copayment* |
| Ambulance | 90% after Deductible | 90% after Deductible |
Outpatient Surgery
| Benefit | In-Network | Out-of-Network |
| Hospital Outpatient Surgery | 90% after Deductible | 70% after Deductible |
| Surgery in an Ambulatory SurgiCenter | 90% after Deductible | 70% after Deductible |
Mental Health Services
| Benefit | In-Network | Out-of-Network |
| Inpatient | 90% after Deductible | 70% after Deductible |
| Outpatient* | 90% after Deductible | 70% after Deductible |
Substance Abuse Services
| Benefit | In-Network | Out-of-Network |
| Inpatient | 90% after Deductible | 70% after Deductible |
| Outpatient* | 90% after Deductible | 70% after Deductible |
Other Services
| Benefit | In-Network | Out-of-Network |
| Durable Medical Equipment Durable medical equipment over $500 require pre-approval. |
90% after Deductible | 70% after Deductible |
| Home Health Care Limited to 100 visits maximum per calendar year for in-network & out-of network services combined. |
90% after Deductible | 70% after Deductible |
| Hospice Care Limited to 180 day maximum per lifetime for in-network & out-of network services combined. |
90% after Deductible | 70% after Deductible |
| Skilled Nursing Limited to 60 days maximum per calendar year for in-network & out-of-network services combined. |
90% after Deductible | 70% after Deductible |
| Routine Vision Care (Exam) | Not Covered | Not Covered |
| Vision Care (Hardware) | Not Covered | Not Covered |
| Infertility Limited to $15,000 maximum per lifetime for in-network & out-of network services combined |
90% after Deductible | 70% after Deductible |
| Non-routine Laboratory, X-ray/ Radiology Services | 90% after Deductible | 70% after Deductible |
Prescription Drugs
Covered with Express Scripts.
Eligibility
Children Eligible To Age 26 and removed at the End of the Calendar Month they turn 26.
Prior Authorization
Some services/procedures require prior authorization. For a complete list, contact our customer service number at 1-800-355-BLUE (2583).
