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 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 Labs
- Prescriptions
- Reimbursement
- Deductibles
- Coinsurance
- Copayments
- Maximum Out-of-Pocket Limits
- Prior Authorization/Precertification
- Participating Physician Responsibilities
- Mailing/Contact Information
- OMNIA ID Cards
- OMNIA Health Plans: Benefit Overviews
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).
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.
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.
PCP Selection
PCP selection is not required for members enrolled in OMNIA Health Plans.
Referrals
Referrals are not required for members enrolled in OMNIA Health plans.
Out-of-Network Benefits
OMNIA Health Plans do not include out-of-network benefits (except in the event of an emergency).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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)
* 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
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 |
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*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 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.
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 |
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* 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 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.
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 |
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*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 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.
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.
