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 |
