RWJBH OMNIA Health Plan

Note:

LabCorp and Quest are the preferred Independent Lab partners for Horizon.
Plan benefits for out-of-network are based on an allowed amount fee schedule, not on provider billed charges, therefore, members using out-of-network providers may have additional out-of-pocket costs.
As of January 1, 2020 prescriptions filled at CVS pharmacies will not be covered.
For medical expenses related to an automobile accident, the RWJBarnabas Health medical plan pays as secondary coverage to the automobile insurance plan.

Routine Adult Physical Exams (1 per calendar year), Immunizations, Routine Child Exams, Routine GYN Exam, Routine Mammogram, Prostate Exam

Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
Plan pays 100%	Plan pays 100%	Plan pays 100%	Plan pays 100%

	Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
PCP	$15 copay (waived at physicians office)	$15 copay - no deductible	$30 copay - no deductible	$50 copay - no deductible
Specialist	$35 copay (waived at physicians office)	$35 copay - no deductible	$70 copay - no deductible	$100 copay - no deductible

$5 copay

One exam per 12 months for all ages

Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
Plan pays 100%	Plan pays 100%	Plan pays 100%	Plan pays 100%

	Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
Physician Office or Independent lab	100% covered at RWJBH	100% covered at LabCorp & Quest	Plan pays 100%	Plan pays 100%
Outpatient Facility	Plan pays 100%	Plan pays 100%	$70 copay	$100 copay

Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
Plan pays 100%	$35 copay - no deductible	$70 copay - no deductible	$100 copay - no deductible

Plan pays 100% after $100 copay—no deductible

Speech/Physical/Occupational Therapy: 30 visit maximum PER therapy, PER condition, PER incident

	Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
RWJBH Facility	Plan pays 100%—no deductible	$35 copay—no deductible	$70 copay—no deductible	$100 copay—no deductible
PCP	$15 copay (waived at physicians office)	$15 copay—no deductible	$30 copay—no deductible	$50 copay—no deductible
Specialist	$35 copay (waived at physicians office	$35 copay—no deductible	$70 copay—no deductible	$100 copay—no deductible

	Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
Plan pays 100%	Plan pays 70%*	Plan pays 50%*	Plan pays 40%*

	Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
Facility	Plan pays 100%	Plan pays 100%	$1,000 copay per admission then Plan pays 50%*	Plan pays 40%*
Physician	Plan pays 100%	Plan pays 70%*	Plan pays 50%*	Plan pays 40%*

	Domestic Tier	Inner Circle	OMNIA Tier 1	Tier 2 (BlueCard® outside of NJ)
Outpatient/Freestanding Facility	Plan pays 100%	Plan pays 70%*	Plan pays 50%*	Plan pays 40%*
Physician Office	Plan pays 100%	Plan pays 100%	Plan pays 100% after office visit copay	Plan pays 100% after office visit copay

Includes medical and prescription drug deductible, coinsurance and copays