OMNIA Health Plans

Our 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 OMNIA Health Plans for individuals, families and groups:

• Primary Care Physician (PCP) selection is not required.
• Referrals are not required. 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 individual consumer, small employer, large group employers, National Accounts, Account Services Only (ASOs), Labor Accounts and Public Sector Accounts may 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 Plan Products
• Participating Networks
• OMNIA Health Plans: Provider Tier Status
• PCP Selection
• Referrals
• Out-of-Network Benefits
• BlueCard® (Out-of-Area) Benefits
• Well Care
• Clinical Laboratory Services
• Prescriptions
• Reimbursement
• Deductibles
• Coinsurance
• Copays
• Maximum Out-of-Pocket Limits
• Prior Authorization/Precertification
• Participating Physician Responsibilities
• Mailing/Contact Information
• OMNIA ID Cards
• OMNIA Health Plans: Benefit Overviews
  • Individual Consumer OMNIA Health Plans
  • Small Group OMNIA Health Plans
  • SHBP OMNIA Health Plan

OMNIA Health Plans

The following are our standard metallic plan offerings that are available both on and off the Health Insurance Marketplace 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.
• 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.
• 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. 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.
• Gold plans, on average, pay for 80 percent of the covered medical expenses; members pay 20 percent.

OMNIA PLATINUM – Small Employer groups only

• Highest monthly premium and lowest out-of-pocket costs compared to other OMNIA Health Plans.
• Platinum plans, on average, pay for 90 percent of the covered medical expenses; members pay 10 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).

return to top

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.

return to top

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 physician tier-status designations for our OMNIA Health Plans.

return to top

PCP Selection

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

return to top

Referrals

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

return to top

Out-of-Network Benefits

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

return to top

BlueCard® (Out-of-Area) Benefits

OMNIA Health Plans available to members in the individual consumer and small employer markets may include BlueCard (out-of-area) benefits

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.

return to top

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., copay, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates in the Horizon Managed Care Network.

return to top

Clinical Laboratory Services

Members enrolled in OMNIA Health Plans have a choice of receiving care for in-network laboratory services at LabCorp and Quest Diagnostics. Members are encouraged to check for in-network laboratories.

Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ Managed Care Plans by a practice that participates in OMNIA Health Plans are allowed as an exception to the above-described LabCorp/Quest network use requirements.

return to top

Prescriptions

All standard OMNIA Health Plans offered on and off the Health Insurance Marketplace 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.

return to top

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.

return to top

Deductibles

OMNIA Health Plans generally include two deductible amounts:

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

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

return to top

Coinsurance

OMNIA Health Plans generally include two coinsurance rates:

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

return to top

Copays

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

• Non-preventive services provided by a Horizon 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)

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

return to top

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 Tier 1.
• OMNIA 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 copays, 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.

return to top

Prior Authorization/Precertification

Certain services/supplies require prior authorization. Call 1-800-664-2583 or submit prior authorization requests through our online Utilization Management Request Tool, unless otherwise noted below:

• Mental health and substance abuse: Call Horizon Behavioral Health at 1-800-626-2212.
• 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.

return to top

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 Horizon Hospital Networks and participating Horizon Managed Care Network physicians, other health care professional and ancillary providers.

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 Horizon Hospital Networks and participating Horizon Managed Care Network physicians, other health care 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.

return to top

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:

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.

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).

return to top

OMNIA Health Plan ID Cards

Horizon BCBSNJ member ID cards contain the important information you need in a consistent layout so that our member 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 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)

return to top

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