Basic/High Deductible Plan
The Basic/High Deductible Plan is a high deductible option for coverage, with 100% coverage after you’ve met your deductible when you use Inner Circle providers. And with BlueCard®, you can take advantage of our network of providers when you are outside of New Jersey.
Annual Deductible
Inner Circle | Horizon PPO Network | Out-of-Network | |
Individual | $1,500 | $1,500 | $3,000 |
Family | $3,000 | $3,000 | $6,000 |
Coinsurance
Inner Circle | Horizon PPO Network | Out-of-Network |
Plan Pays 100% | Plan Pays 60% | Plan Pays 50% |
Out-Of-Pocket Maximum
Inner Circle | Horizon PPO Network | Out-of-Network | ||
Individual (Medical & Rx) | $2,000 | $6,650 | $6,650 | |
Family (Medical & Rx) | $4,000 | $13,300 | $13,300 | |
Lifetime Maximum | Unlimited | Unlimited | Unlimited | Unlimited |
Precertification Requirements
$400 Penalty Applies For Each Failure To Precert
Inpatient Covered Services
Inner Circle | Horizon PPO Network | Out-of-Network | |
Hospital
Copay Applied Before Deductible, Per Admission |
None | None | None |
Semi-Private Room | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Inpatient Physician | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Surgery Direct | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Outpatient Covered Services
Inner Circle | Horizon PPO Network | Out-of-Network | |
Primary Care Office Visit | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Specialist Visit | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Outpatient Surgery | 100% After Deductible | 60% After Deductible | Surgi-Center – Not Covered All Other Facilities - 50% After Deductible |
Preventive Care Including Routine Physicals & Immunizations Frequency Limits May Apply |
100% | 100% | Not Covered |
Chiropractic Care 30 Visits Per Year |
100% After Deductible | 60% After Deductible | 50% After Deductible |
Diagnostic X-Ray, Lab Services And Treatments | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Mental Health/Substance Abuse
Inner Circle | Horizon PPO Network | Out-of-Network | |
Inpatient Care | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Outpatient | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Emergency Services
Inner Circle | Horizon PPO Network | Out-of-Network | |
Emergency Room | 100% After Deductible | 100% After Deductible | 100% After Deductible |
Ambulance Service (Medically Necessary) |
100% After Deductible | 100% After Deductible | 100% After Deductible |
Urgent Care | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Other Services
Inner Circle | Horizon PPO Network | Out-of-Network | |
Physical, Occupational, Speech and Cognitive Therapy 60 Visits Per Year |
100% After Deductible | 60% After Deductible | 50% After Deductible |
Radiation, Chemotherapy And Cardiac Therapy | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Dialysis | 100% After Deductible | 60% After Deductible | Not Covered |
Home Health Care 120 Visits Per Year |
100% After Deductible | 60% After Deductible | 50% After Deductible |
Extended Care/ Skilled Nursing 120 Visits Per Year |
100% After Deductible | 60% After Deductible | 50% After Deductible |
Hospice Care | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Durable Medical Equipment | 100% After Deductible | 60% After Deductible | 50% After Deductible |
Acupuncture Includes Coverage For Pain Management | 100% After Deductible | 60% After Deductible | Not Covered |