MyWay HSA
You may access your Health Savings Account for out of pocket expenses.
The employee can contribute to the Health Savings Account up to the statutory maximum regardless of the individual's deductible.
Benefit Period
The Benefit period is for the contract year.
Deductible
| In-Network | Out-of-Network | |
| Individual | $2000 per indiv./$4000 True Family Deductible | |
| Family | True Family Aggregate - Entire family deductible must be met before any benefits are paid. | |
Deductible is Contract Year.
Coinsurance (Horizon Pays)
| In-Network | Out-of-Network | |
| Coinsurance (Horizon Pays) | 100% after deductible | 70% after deductible |
Coinsurance (Member Pays)
| In-Network | Out-of-Network | |
| Coinsurance (Member Pays) | 0% after deductible | 30% after deductible |
Maximum Out of Pocket
| In-Network | Out-of-Network | |
| Individual | $6,900 | $10,000 |
| Family | $13,800 | $20,000 |
Consolidated Maximum Out of Pocket is Contract Year. The deductible, coinsurance, and prescription 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
Unlimited
Lifetime Maximum
Unlimited
Primary Care Physician Selection
Not Required
Doctor’s Office Visits
| In-Network | Out-of-Network | |
| Primary Care Office Visit | 100% after deductible | 30% after deductible |
| A primary care physician is a general or family practitioner, internist or pediatrician | ||
| Specialist Office Visit | 100% after deductible | 30% after deductible |
| A referral is not required to visit a specialist. | ||
| Maternity Visits | 100% after deductible | 30% after deductible |
| Female child dependents are eligible for maternity/obstetrical benefits. | ||
| Allergy Testing and Treatment | 100% after deductible | 30% after deductible |
Preventive Care
| In-Network | Out-of-Network | |
| Routine Adult Physicals, GYN Exams, PAP, Mammograms, Prostate Cancer Screening, Colorectal Screening, Immunizations |
100% (no deductible) | 30% (no deductible) |
| Well Child Exams | 100% (no deductible) | 30% (no deductible) |
| Well Child Immunizations and Lead Screening | 100% (no deductible) | 30% (no deductible) |
Diagnostic Procedures
| In-Network | Out-of-Network | |
| Laboratory | 100% after deductible | 30% after deductible |
| Outpatient X-ray/Radiology Services | 100% after deductible | 30% after deductible |
Hospital Care
| In-Network | Out-of-Network | |
| Inpatient Admission (including maternity) |
100% after deductible | 30% after deductible |
| Pre-admission Testing | 100% after deductible | 30% after deductible |
| Surgery in Hospital | 100% after deductible | 30% after deductible |
| Inpatient Physician Services | 100% after deductible | 30% after deductible |
| Outpatient Dept. Services | 100% after deductible | 30% after deductible |
Emergency Care
| In-Network | Out-of-Network | |
| Emergency Room | 100% after deductible Payment at the in-network level across-the-board applies only to true Medical Emergencies & Accidental |
|
| Ambulance | 100% after deductible | 30% after deductible |
Outpatient Surgery
| In-Network | Out-of-Network | |
| Hospital Outpatient Surgery | 100% after deductible | 30% after deductible |
| Surgery in an Ambulatory SurgiCenter | 100% after deductible | 30% after deductible |
| Services performed at a non-participating ambulatory surgery center are reimbursed at Horizon BCBSNJ's Payment Allowance and therefore may result in significant out of pocket costs. | ||
Mental Health Services
| In-Network | Out-of-Network | |
| Inpatient | 100% after deductible | 30% after deductible |
| Outpatient department | 100% after deductible | 30% after deductible |
| Office setting | 100% after deductible | 30% after deductible |
| Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212. | ||
Substance Abuse Services
| In-Network | Out-of-Network | |
| Inpatient | 100% after deductible | 30% after deductible |
| Outpatient department | 100% after deductible | 30% after deductible |
| Office setting | 100% after deductible | 30% after deductible |
| Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212. | ||
Alcohol Abuse Services
| In-Network | Out-of-Network | |
| Inpatient | 100% after deductible | 30% after deductible |
| Outpatient department | 100% after deductible | 30% after deductible |
| Office setting | 100% after deductible | 30% after deductible |
| Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212. | ||
Other Services
| In-Network | Out-of-Network | |
| Bariatric Surgery | 100% after deductible | 30% after deductible |
| Diabetic Education | 100% after deductible | 30% after deductible |
| Durable Medical Equipment (including diabetic supplies) |
100% after deductible | 30% after deductible |
| Orthotics and Prosthetics | 100% after deductible | 30% after deductible |
| Home Health Care | 100% after deductible | 30% after deductible |
| 90 visit maximum per benefit period, direct admission | ||
| Hospice Care | 100% after deductible | 30% after deductible |
| Unlimited lifetime maximum | ||
| Infertility | 100% after deductible | 30% after deductible |
| Private Duty Nursing | 100% after deductible | 30% after deductible |
| Limited to 240 hours per benefit period | ||
| Short-term Therapies: Physical, Occupational, Speech, Cognitive (Limit of 3 modalities per visit – out of network only) |
100% after deductible | 30% after deductible |
| 40 visit maximum per therapy, per benefit period | ||
| Skilled Nursing Facility/Extended Care Center | 100% after deductible | 30% after deductible |
| 120 days per benefit period, following a 3 or more day prior hospital stay. | ||
| Therapeutic Manipulation (Chiropractic Care) | 100% after deductible | 30% after deductible |
| 30 visit maximum per benefit period | ||
| Routine Vision Exam | 100% after deductible | 30% after deductible |
| Vision Hardware | $100 in a 2 calendar year period | |
| Telemedicine | Not Covered | |
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.
Prior Authorization
Some services/procedures require prior authorization. For a complete list, contact our customer service number at 1-800-355-BLUE (2583) or refer to our website at HorizonBlue.com.
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.
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.
Services and products provided by Horizon Blue Cross Blue Shield of New Jersey, an independent licensee of the Blue Cross and Blue Shield Association. ® Registered marks of the Blue Cross and Blue Shield Association. ® and ℠ Registered and service marks of Horizon Blue Cross Blue Shield of New Jersey. © 2008 Horizon Blue Cross Blue Shield of New Jersey Three Penn Plaza East, Newark, New Jersey 07105
