OMNIA Health Plans

Our new OMNIA℠ Health Plans give enrolled members the flexibility to use any hospital participating in our Horizon Hospital Network and any participating physician, other health care professional or ancillary provider participating in our Horizon Managed Care Network.

Features of our new OMNIA Health Plans for individuals, families and groups:

  • Primary Care Physician (PCP) selection is not required for members enrolled in OMNIA Health Plans.
  • Referrals are not required for OMNIA Health Plan members. Certain services/supplies do require prior authorization.
  • OMNIA Health Plan members may use any physician or other health care professional from our broad Horizon Managed Care Network and any hospital from the Horizon Hospital Network, but will maximize their benefits and incur lower cost sharing when they use OMNIA Tier 1-designated physicians, other health care professionals, ancillary providers and hospitals.
  • OMNIA Health Plans do not include out-of-network benefits. OMNIA Health Plan members must use physicians and other health care professionals who participate in the Horizon Managed Care Network and hospitals in our Horizon Hospital Network, except in cases of medical emergencies.*

    *OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include BlueCard (out-of-area) coverage.

  • OMNIA Health Plan members have coverage for eligible preventive services (physical exams, well-child care, immunizations, etc.) with no member cost sharing when these services are provided by a physician or other health care professional within the Horizon Managed Care Network.

Click the links below to learn more about our OMNIA Health Plans.

OMNIA Health Plans

The following are our standard metallic plan offerings that are available on and off the health insurance exchange for members in the individual consumer and small employer markets.

OMNIA BRONZE

  • Lowest monthly premium and highest out-of-pocket costs compared to other OMNIA Health Plans. Members must use physicians and other health care professionals who participate in the Horizon Managed Care Network and hospitals in the Horizon Hospital Network, except in cases of medical emergencies.
  • Bronze plans, on average, pay for 60 percent of the covered medical expenses; members pay 40 percent.

OMNIA SILVER

  • Mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Members must use physicians and other health care professionals who participate in the Horizon Managed Care Network and hospitals in the Horizon Hospital Network, except in cases of medical emergencies.
  • Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent.
  • Cost sharing subsidies may be available.

OMNIA SILVER HSA

  • Offered in conjunction with a Health Savings Account (HSA).
  • Mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Members must use physicians and other health care professionals who participate in the Horizon Managed Care Network and hospitals in the Horizon Hospital Network, except in cases of medical emergencies.
  • Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent.
  • Cost sharing subsidies may be available.

OMNIA GOLD

  • Higher monthly premium and lower out-of-pocket costs compared to other OMNIA Health Plans. Members must use physicians and other health care professionals who participate in the Horizon Managed Care Network and hospitals in the Horizon Hospital Network, except in cases of medical emergencies.
  • Gold plans, on average, pay for 80 percent of the covered medical expenses; members pay 20 percent.

Non-standard OMNIA Health Plans

OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options (including pharmacy benefits, BlueCard coverage and variations in out-of-pocket expenses).

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Participating Networks

OMNIA Health Plan members must use physicians, other health care professionals that participate in the Horizon Managed Care Network and hospitals that participate in the Horizon Hospital Network.

OMNIA Health Plan members can incur lower cost sharing when they use OMNIA Tier 1 physicians, other health care professionals, hospitals and ancillary providers.

The OMNIA Health Plan tier status of physicians, other health care professionals, hospitals and ancillary providers may be reviewed on our Doctor & Hospital Finder.

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OMNIA Health Plans: Provider Tier Status

All network hospitals and all physicians, other health care professionals and ancillary providers that participate in our broad Horizon Managed Care Network participate with our OMNIA Health Plans; however, OMNIA Health Plan members:

  • Will incur lower cost sharing when they use OMNIA Tier 1 designated physicians, other health care professionals, hospitals and ancillary providers.

To make it easier for members to understand their cost sharing, all physicians and other health care professionals affiliated with, or who practice under or on behalf of a group practice, will participate with OMNIA Health Plans at the same tier when treating members under a particular group Tax ID Number (TIN).

Ancillary facilities and ancillary professionals that participate in our Horizon Managed Care Network will be designated OMNIA Tier 1. Some exceptions apply.

Access our Doctor & Hospital Finder to review provider tier-status designations for our OMNIA Health Plans.

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PCP Selection

PCP selection is not required for members enrolled in OMNIA Health Plans.

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Referrals

Referrals are not required for members enrolled in OMNIA Health plans.

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Out-of-Network Benefits

OMNIA Health Plans do not include out-of-network benefits (except in the event of an emergency).

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BlueCard® (Out-of-Area) Benefits

OMNIA Health Plans available to members in the individual consumer and small employer markets do not include BlueCard (out-of-area) benefits (except in the event of an emergency).

OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options, including BlueCard coverage.

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Well Care

OMNIA Health Plans cover the all preventive care services identified by the federal health care reform law at 100 percent without any cost sharing (i.e., copayment, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates in the Horizon Managed Care Network.

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Clinical Laboratory Services

LabCorp® is the exclusive in-network provider of clinical laboratory services for members enrolled in OMNIA Health Plans.

Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Managed Care Network are allowed as an exception to the above-described LabCorp exclusivity requirement.

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Prescriptions

All standard OMNIA Health Plans offered on and off the Health Insurance exchange to consumers and small group employers include a pharmacy benefit.

Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts have the option to include a pharmacy benefit in their OMNIA Health Plans.

For OMNIA Health Plan members with pharmacy benefits, Prime Therapeutics is the pharmacy benefits manager. Prior authorization (PA) may be required for some medications. Submit your pharmacy PA requests through NaviNet® or call 1-888-214-1784 if you have questions about a medicine requiring PA.

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Reimbursement

Eligible services provided to OMNIA Health Plan members by participating Horizon Managed Care Network physicians and other health care professionals will be reimbursed at the Horizon Managed Care Network rates.

  • Reimbursement of physicians that participate only in our Horizon PPO Network will be calculated at our PPO allowance and reimbursed based on the OMNIA Health Plan member’s Tier 2 level of benefits.

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Deductibles

OMNIA Health Plans generally include two deductible amounts:

  • OMNIA Tier 1 Deductible—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as OMNIA Tier 1.
  • Tier 2 Deductible—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 2 providers.

The benefit designs of certain OMNIA Health Plans (e.g., Gold and certain Large Group Employer Plans) do not include a deductible for services provided by OMNIA Tier 1 providers.

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Coinsurance

OMNIA Health Plans generally include two coinsurance rates:

  • OMNIA Tier 1 Coinsurance—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as OMNIA Tier 1 providers.
  • Tier 2 Coinsurance—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 2 providers.

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Copayments

OMNIA Health Plans include separate OMNIA Tier 1 and Tier 2 copayments for a number of services, including:

  • Nonpreventive services provided by a managed care network PCP or specialist in an office setting
  • Inpatient hospital care
  • Inpatient behavioral health and substance abuse care
  • Emergency Room services
  • Urgent Care Center services
  • Outpatient Behavioral Health
  • Short-term physical, speech, occupational and/or cognitive therapy services provided in a freestanding office setting (limited to a combined 30 visits per calendar year)
  • Therapeutic manipulation provided in an office setting (limited to 30 visits per calendar year)

Copayments for certain OMNIA Health Plans apply only after the OMNIA Health Plan member’s OMNIA Tier 1 or Tier 2 deductible is satisfied.

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Maximum Out-of-Pocket Limits

OMNIA Health Plans include two separate maximum out-of-pocket (MOOP) limits:

  • OMNIA Tier 1 MOOP—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as OMNIA Tier 1.
  • Tier 2 MOOP—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 2.
  • Where there is an OMNIA Tier 1 deductible, any cost sharing such as copayments, deductible and/or coinsurance expended in connection with an OMNIA Tier 1 covered charge shall also be credited to the Tier 2 deductible. Cost sharing for Tier 2 covered charges are not credited to the OMNIA Tier 1 deductible.

MOOP limits for OMNIA Health Plans for coverage types other than individual (i.e., family, 2-adults, parent/child) include a component for each covered person as well as a “family” limit.

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Prior Authorization/Precertification

Certain services/supplies require prior authorization. Call 1-800-664-2583 or fax 1-877-798-5903 to submit prior authorization requests, unless otherwise noted below:

  • Mental health and substance abuse: Call Horizon Behavioral Health at 1-800-626-2212.
  • Physical therapy: Call 1-888-789-3457 or fax 1-800-723-5188.
  • Medical injectables: For certain intravenous immunoglobulin (IVIG), oncology and rheumatoid arthritis injectable medications, please call Magellan Rx Management at 1-800-424-4508.
  • Non-emergency radiology services, advanced imaging services (MRI, CT, PET scans and nuclear medicine including nuclear cardiology), cardiac imaging services, radiation therapy and pain management services: Call eviCore healthcare at 1-866-496-6200.
  • Horizon Care@Home Program services (including in-home nursing services, physical therapy, occupational therapy and speech therapy): Horizon BCBSNJ conducts the review of these requests. Prior authorization requests for these services must be submitted using Horizon BCBSNJ’s online utilization management request tool via NaviNet.

CareCentrix conducts the review of requests for Horizon Care@Home services for: Durable Medical Equipment (including Medical Foods [Enteral], and Diabetic and Other Medical Supplies); Orthotics and Prosthetics and Home Infusion Therapy Services, including hemophilia. Call 1-855-243-3321 to initiate the review of these services.

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Participating Physician Responsibilities

Participating Network

OMNIA Health Plan members must use physicians and other health care professionals that participate in the Horizon Managed Care Network and hospitals that participate in the Horizon Hospital Network.

OMNIA Health Plan members incur lower cost sharing when they use OMNIA Tier 1 physicians, other health care professionals, hospitals and ancillary providers.

OMNIA Health Plan members have no out-of-network benefits (except in the event of an emergency).

Please use our Doctor & Hospital Finder to locate OMNIA Tier 1 and Tier 2 designated network hospitals and participating Horizon Managed Care Network physicians, other health care professional and ancillary providers.

Review the Physician and Other Health Care Professionals Frequently Asked Questions document.

Referrals

Based on the guidelines of our administrative policy, OMNIA Health Plan Tier Awareness, Horizon BCBSNJ requires that participating physicians and other health care professionals who are treating/coordinating the care of members and/or dependents enrolled in an OMNIA Health Plan discuss the cost sharing implications of using physicians, other health care professionals and facilities designated as OMNIA Tier 1 or Tier 2 with these patients (or their parents, guardians or designated personal representatives).

This conversation should be conducted at the time a determination to refer or recommend a patient to a physician, other health care professional and/or facility occurs and should be fully documented within the OMNIA Health Plan members/covered persons’ medical record.

The participating physician or other health care professional is responsible for retaining this information in the patient’s medical record and for making such documentation available, upon request by Horizon BCBSNJ, within 10 business days from the date of a request to review this information.

Our administrative policy, OMNIA Health Plan Tier Awareness, is available online for your review.

Please use our Doctor & Hospital Finder to locate OMNIA Tier 1 and Tier 2 designated network hospitals and participating Horizon Managed Care Network physicians, other healthcare professional and ancillary providers.

Prior Authorization

Certain services require prior authorization (PA). Review a list of services that require PA.

Prescription Drug Prior Authorization

Certain prescription drugs require prior authorization.

We encourage you to use the NaviNet Drug Authorization tool to quickly and easily submit and manage your drug PAs. Access NaviNet Drug Authorizations to register and for more information. Physicians are encouraged to prescribe appropriate first-line agents before using alternative drugs.

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Mailing/Contact Information

Claims

Claims for services provided to members enrolled in OMNIA Health Plans may be submitted to us electronically. Claims may also be submitted hard copy to the following addresses:

Type of service Claim submission address Inquiry submission address
Professional Horizon BCBSNJ
PO Box 1609
Newark, NJ 07101-1609
Horizon BCBSNJ
PO Box 199
Newark, NJ 07101-0199
Facility Horizon BCBSNJ
PO Box 25 
Newark, NJ 07101-0025
Horizon BCBSNJ
PO Box 1770
Newark, NJ 07101-1770
Pharmacy Prime Therapeutics
PO Box 64812 
St. Paul, MN 55164-4812
Prime Therapeutics
P.O. Box 64812
St. Paul, MN 55164-4812

 

Service

Horizon BCBSNJ has a number of service areas that can assist with authorizations and prior authorizations. For these specialized service areas to perform their functions efficiently and effectively, it’s important that their time is not spent responding to basic benefits, enrollment and eligibility inquiries.

Please seek basic benefits, enrollment and eligibility information prior to contacting our Precertification Call Center for an authorization request. If you require documentation that a service does not require precertification, a Physician Services Representative can provide both the information you need and a service reference number that documents the information you were provided.

Service area Telephone number
Physician Services 1-800-624-1110
Institutional Services 1-888-666-2535
Prior Authorization Requests 1-800-664-BLUE (2583)
Horizon Behavioral Health 1-800-626-2212
Horizon Pharmacy Program 1-800-370-5088
eviCore healthcare 1-866-496-6200
Horizon Care@Home Program (for DME, O&P, HIT services, including hemophilia, and diabetic and other medical supplies only)1 1-855-243-3321
Medical Injectables Program 1-800-424-4508
Dental 1-800-4-DENTAL (433-6825)
Physical Therapy Unit 1-888-789-3457
Member Services 1-800-355-BLUE (2583)

 

1For Home Health Services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), please call Prior Authorization Requests: 1-800-664-BLUE(2583).

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OMNIA ID Cards

Horizon BCBSNJ ID cards contain the important information you need in a consistent layout so that our ID cards are easy to read and use.

Members enrolled in OMNIA Health Plans have ID cards similar to the sample ID card below. Please also take note of the three-letter prefix. The prefix can help identify the plan in which the patient is enrolled and is critical for verifying benefits and eligibility and for submitting claims.

OMNIA Health Plan ID cards may include one of the following prefixes:
         YKS (off exchange)*
         YKF (on exchange)
         NJO (SHBP OMNIA Health Plan offering)

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* Large Group Employer OMNIA Health Plan ID cards may include the YKS prefix or a prefix customized by that group.

OMNIA Bronze – Individual/Consumer Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.

  OMNIA Tier 1 Tier 2
Deductible $3,000 individual/$6,000 family $3,000 individual/$6,000 family
Coinsurance 50% 50%
Maximum Out-of-Pocket $7,150 individual/$14,300 family $7,150 individual/$14,300 family
Primary Care Physician* $30 copayment after deductible 50% coinsurance after deductible
Specialist $50 copayment 50% coinsurance after deductible
Inpatient Hospital $500 copayment per day 50% coinsurance after deductible
Emergency Room (ER) $100 copayment, then 50% coinsurance after deductible $100 copayment, then 50% coinsurance after deductible
Outpatient Surgery Copayment (Facility) 50% coinsurance after deductible 50% coinsurance after deductible
Laboratory Services - Hospital Outpatient No charge 50% coinsurance after deductible
Radiology Services - Hospital Outpatient No charge 50% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding 50% coinsurance after deductible 50% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient 50% coinsurance after deductible 50% coinsurance after deductible
Urgent Care $30 copayment after deductible 50% coinsurance after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) No charge 50% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient $500 copayment per day after deductible 50% coinsurance after deductible
Home Health Care $30 copayment after deductible **
Skilled Nursing Care 50% coinsurance after deductible **
Durable Medical Equipment (DME) 50% coinsurance after deductible **
Hospice $500 copayment per day after deductible **
Prescriptions 50% coinsurance after deductible

 

*OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
** All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply

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OMNIA Silver – Individual/Consumer Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.

In compliance with the requirements of the Affordable Care Act (ACA), member cost sharing (copayments, deductibles, coinsurance and maximum out-of-pocket levels) may vary based upon the enrollee’s income level.

The cost sharing amounts/percentages indicated in the table below reflect the base plan (members who do not qualify for any subsidies). An enrolled member’s actual cost sharing amounts will be determined by the cost sharing subsidy he/she qualifies for based on income level. Those specific cost sharing amounts and levels will be included on the member’s ID card.

  OMNIA Tier 1 Tier 2
Deductible $0 $2,500 individual/$5,000 family
Coinsurance 100% 50%
Maximum Out-of-Pocket $7,150 individual/$14,300 family $7,150 individual/$14,300 family
Primary Care Physician* $30 copayment 50% coinsurance after deductible
Specialist $50 copayment 50% coinsurance after deductible
Inpatient Hospital $500 copayment per day 50% coinsurance after deductible
Emergency Room (ER) $100 copayment, then 70% coinsurance after $900 ER deductible $100 copayment, then 50% coinsurance after deductible
Outpatient Surgery Copayment (Facility) $250 copayment 50% coinsurance after deductible
Laboratory Services - Hospital Outpatient No charge copayment No charge coinsurance after deductible
Radiology Services - Hospital Outpatient No charge copayment No charge coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding $50 copayment 50% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient $50 copayment 50% coinsurance after deductible
Urgent Care $30 copayment 50% coinsurance after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) No charge copayment 50% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient $500 copayment per day 50% coinsurance after deductible
Home Health Care $30 copayment **
Skilled Nursing Care $500 copayment per day **
Durable Medical Equipment (DME) No charge **
Hospice $500 copayment per day **
Pharmacy Generics: $15 copayment Preferred Brands: 50% coinsurance
Non-Preferred Brands: 50% coinsurance

 

*OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
** All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply

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OMNIA Silver HSA – Individual/Consumer Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.

In compliance with the requirements of the Affordable Care Act (ACA), member cost sharing (copayments, deductibles, coinsurance and maximum out-of-pocket levels) may vary based upon the enrollee’s income level.

The cost sharing amounts/percentages indicated in the table below reflect the base plan (members who do not qualify for any subsidies). An enrolled member’s actual cost sharing amounts will be determined by the cost sharing subsidy he/she qualifies for based on income level. Those specific cost sharing amounts and levels will be included on the member’s ID card.

  OMNIA Tier 1 Tier 2
Deductible $1,500 individual/$3,000 family $2,500 individual/$5,000 family
Coinsurance 90% 70%
Maximum Out-of-Pocket $3,600 individual/$7,200 family $6,550 individual/$13,100 family
Primary Care Physician* $10 copayment after deductible $25 copayment after deductible
Specialist $20 copayment after deductible $50 copayment after deductible
Inpatient Hospital 90% coinsurance after deductible 70% coinsurance after deductible
Emergency Room (ER) $100 copayment, then 90% coinsurance after deductible $100 copayment, then 70% coinsurance after deductible
Outpatient Surgery Copayment (Facility) 100% coinsurance after deductible 70% coinsurance after deductible
Laboratory Services - Hospital Outpatient 100% coinsurance after deductible 70% coinsurance after deductible
Radiology Services - Hospital Outpatient 100% coinsurance after deductible 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding 90% coinsurance after deductible 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient 90% coinsurance after deductible 70% coinsurance after deductible
Urgent Care $10 copayment after deductible $25 copayment after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) 90% coinsurance after deductible 70% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient 90% coinsurance after deductible 70% coinsurance after deductible
Home Health Care 90% coinsurance after deductible **
Skilled Nursing Care 90% coinsurance after deductible **
Durable Medical Equipment (DME) 90% coinsurance after deductible **
Hospice 90% coinsurance after deductible **
Pharmacy 60% coinsurance after deductible

 

* OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
** All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply.

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OMNIA Gold – Individual/Consumer Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.

  OMNIA Tier 1 Tier 2
Deductible $0 $2,500 individual/$5,000 family
Coinsurance 100% 70%
Maximum Out-of-Pocket $3,500 individual/$7,000 family $6,350 individual/$12,700 family
Primary Care Physician* $10 copayment $30 copayment after deductible
Specialist $25 copayment $50 copayment after deductible
Inpatient Hospital $500 per day 70% coinsurance after deductible
Emergency Room (ER) $100 copayment $100 copayment, then 70% coinsurance after deductible
Outpatient Surgery Copayment (Facility) $250 copayment 70% coinsurance after deductible
Laboratory Services – Hospital Outpatient No charge 70% coinsurance after deductible
Radiology Services – Hospital Outpatient No charge 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding $20 copayment 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient $20 copayment 70% coinsurance after deductible
Urgent Care $10 copayment $30 copayment after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) $20 copayment 70% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient $500 copayment per day 70% coinsurance after deductible
Home Health Care $20 copayment **
Skilled Nursing Care $500 copayment per day **
Durable Medical Equipment (DME) No charge **
Hospice $500 copayment per day **
Pharmacy Generics: $10 copayment Preferred Brands: 60% coinsurance
Non-Preferred Brands: 50% coinsurance

 

* OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
** All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply.

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OMNIA Bronze – Small Group Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.

  OMNIA Tier 1 Tier 2
Deductible $3,000 individual/$6,000 family $3,000 individual/$6,000 family
Coinsurance 50% 50%
Maximum Out-of-Pocket $7,150 individual/$14,300 family $7,150 individual/$14,300 family
Primary Care Physician* $30 copayment after deductible 50% coinsurance after deductible
Specialist $50 copayment after deductible 50% coinsurance after deductible
Inpatient Hospital $500 copayment per day after deductible 50% coinsurance after deductible
Emergency Room (ER) $100 copayment, then 50% coinsurance after deductible $100 copayment, then 50% coinsurance after deductible
Outpatient Surgery Copayment (Facility) 50% coinsurance after deductible 50% coinsurance after deductible
Laboratory Services - Hospital Outpatient 100% coinsurance after deductible 50% coinsurance after deductible
Radiology Services - Hospital Outpatient 100% coinsurance after deductible 50% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding 50% coinsurance after deductible 50% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient 50% coinsurance after deductible 50% coinsurance after deductible
Urgent Care $30 copayment after deductible 50% coinsurance after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) 50% coinsurance after deductible 50% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient $500 copayment per day after deductible 50% coinsurance after deductible
Home Health Care $30 copayment after deductible **
Skilled Nursing Care 50% coinsurance after deductible **
Durable Medical Equipment (DME) 50% coinsurance after deductible **
Hospice $500 copayment per day after deductible **
Pharmacy 50% coinsurance after deductible

 

* OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
** All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply.

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OMNIA Silver – Small Group Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services.

  OMNIA Tier 1 Tier 2
Deductible $0 2,500 individual/$5,000 family
Coinsurance 100% 50%
Maximum Out-of-Pocket $7,150 individual/$14,300 family $7,150 individual/$14,300 family
Primary Care Physician* $30 copayment 50% coinsurance after deductible
Specialist $50 copayment 50% coinsurance after deductible
Inpatient Hospital $500 copayment per day 50% coinsurance after deductible
Emergency Room (ER) $100 copayment, then 70% coinsurance after $900 ER deductible $100 copayment, then 50% coinsurance after deductible
Outpatient Surgery Copayment (Facility) $250 copayment 50% coinsurance after deductible
Laboratory Services - Hospital Outpatient $50 copayment 50% coinsurance after deductible
Radiology Services - Hospital Outpatient No charge 50% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding No charge 50% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient $30 copayment 50% coinsurance after deductible
Urgent Care $30 copayment 50% coinsurance after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) No charge 50% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient $500 copayment per day 50% coinsurance after deductible
Home Health Care $30 copayment **
Skilled Nursing Care $500 copayment per day **
Durable Medical Equipment (DME) 50% coinsurance **
Hospice $500 copayment per day **
Pharmacy Generics: $15 copayment Preferred Brands: 50% coinsurance
Non-Preferred Brands: 50% coinsurance

 

*OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
**All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply.

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OMNIA Silver HSA – Small Group Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.

  OMNIA Tier 1 Tier 2
Deductible $1,500 individual/$3,000 family $2,500 individual/$5,000 family
Coinsurance 90% 70%
Maximum Out-of-Pocket $3,600 individual/$7,200 family $6,550 individual/$13,100 family
Primary Care Physician* $10 copayment after deductible $25 copayment after deductible
Specialist $20 copayment after deductible $50 copayment after deductible
Inpatient Hospital 90% coinsurance after deductible 70% coinsurance after deductible
Emergency Room (ER) $100 copayment, then 90% coinsurance after deductible $100 copayment, then 70% coinsurance after deductible
Outpatient Surgery Copayment (Facility) 90% coinsurance after deductible 70% coinsurance after deductible
Laboratory Services - Hospital Outpatient 100% coinsurance after deductible 70% coinsurance after deductible
Radiology Services - Hospital Outpatient 100% coinsurance after deductible 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding 90% coinsurance after deductible 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient 90% coinsurance after deductible 70% coinsurance after deductible
Urgent Care $10 copayment after deductible $25 copayment after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) 90% coinsurance after deductible 70% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient 90% coinsurance after deductible 70% coinsurance after deductible
Home Health Care 90% coinsurance after deductible **
Skilled Nursing Care 90% coinsurance after deductible **
Durable Medical Equipment (DME) 90% coinsurance after deductible **
Hospice 90% coinsurance after deductible **
Pharmacy 60% coinsurance after deductible

 

*OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
** All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply.

OMNIA Gold – Small Group Market
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.

  OMNIA Tier 1 Tier 2
Deductible $0 $2,500 individual/$5,000 family
Coinsurance 100% 70%
Maximum Out-of-Pocket $3,500 individual/$7,000 family $6,350 individual/$12,700 family
Primary Care Physician* $10 copayment $30 copayment after deductible
Specialist $25 copayment $50 copayment after deductible
Inpatient Hospital $500 copayment per day 70% coinsurance after deductible
Emergency Room (ER) $100 copayment $100 copayment, then 70% coinsurance after deductible
Outpatient Surgery Copayment (Facility) $250 copayment 70% coinsurance after deductible
Laboratory Services - Hospital Outpatient No charge 70% coinsurance after deductible
Radiology Services - Hospital Outpatient No charge 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding $20 copayment 70% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient $20 copayment 70% coinsurance after deductible
Urgent Care $10 copayment $30 copayment after deductible
Behavioral Health and Substance Abuse Outpatient (Facility) $20 copayment 70% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient $500 copayment per day 70% coinsurance after deductible
Home Health Care $20 copayment **
Skilled Nursing Care $500 copayment per day **
Durable Medical Equipment (DME) 50% coinsurance **
Hospice $500 copayment per day **
Pharmacy Generics: $10 copayment
Preferred Brands: 60% coinsurance
Non-Preferred Brands: 50% coinsurance

 

*OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
**All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply.

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NJ SHBP/SEHBP OMNIA Health Plan
All hospitals in the Horizon Hospital Network and all Horizon Managed Care Network physicians and other health care professionals are considered in network for OMNIA Health Plan members. OMNIA Health Plan members will have lower out-of-pocket costs if they receive care from OMNIA Tier 1 hospitals and physicians.

Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts that select OMNIA Health Plans have the ability to customize their OMNIA benefits programs to include a range of benefit options, including BlueCard coverage and variations in out-of-pocket costs.

  OMNIA Tier 1 Tier 2
Deductible $0 $1,500 individual/$3,000 family
Coinsurance 100% 80%
Maximum Out-of-Pocket $2,500 individual/$5,000 family $4,500 individual/$9,000 family
BlueCard (out-of-area) Coverage - Yes
Primary Care Physician* $5 copayment $30 copayment after deductible
Specialist $15 copayment $50 copayment after deductiblet
Inpatient Hospital $150 per admission 70% coinsurance after deductible
Emergency Room (ER) $100 copayment $100 copayment, then 70% coinsurance after deductible
Outpatient Surgery Copayment (Facility) $150 copayment 80% coinsurance after deductible
Laboratory Services - Hospital Outpatient $15 copayment 80% coinsurance after deductible
Radiology Services - Hospital Outpatient $15 copayment 80% coinsurance after deductible
Imaging (CT/PET scans, MRIs) –Freestanding $15 copayment 80% coinsurance after deductible
Imaging (CT/PET scans, MRIs) – Hospital Outpatient $15 copayment 80% coinsurance after deductible
Urgent Care $15 copayment $30 copayment
Behavioral Health and Substance Abuse Outpatient (Facility) $15 copayment 80% coinsurance after deductible
Behavioral Health and Substance Abuse Inpatient No copayment 80% coinsurance after deductible
Home Health Care** $5 copayment $5 copayment
Skilled Nursing Care** $150 per admission 80% coinsurance after deductible
Durable Medical Equipment (DME)** No charge 80% coinsurance after deductible
Hospice** No copayment $150 per admission

 

*OMNIA Health Plan members are not required to select a Primary Care Physician (PCP). Referrals are not required to seek specialty care.
**All participating Horizon Managed Care Network ancillary providers and ancillary facilities are designated OMNIA Tier 1. Some exceptions apply. The Tier 2 level of benefits applies to ancillary provider services provided through member’s BlueCard benefits.