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 |
Portable Benefits Coverage
The BlueCard® PPO program links you directly to care anywhere in the country and in the world. So, whether traveling or living in another state, members can take advantage of their benefits by presenting their ID cards to any participating doctor or hospital. Once enrolled, members simply carry our easily identifiable ID cards with a PPO in a suitcase logo, which lists a toll-free number to help reach a BlueCard PPO provider.
