Direct Access Plan for RWJBH BHealthy Care

The Direct Access Plan offers you the freedom of choosing from three levels of coverage: RWJBarnabas Health Inner Circle/Premier providers, Horizon Direct Access in-network, and out-of-network.

RWJBarnabas Health Premier providers include RWJBH hospitals and labs, the Medical Group, and Joint Venture facility and physician groups of RWJBH. RWJBarnabas Health Inner Circle providers are healthcare providers that are affiliated with the RWJBH healthcare system. They are doctors that have admitting privileges and work closely with RWJBH, but are not employed by RWJBH. Using providers in the RWJBarnabas Health Premier/Inner Circle provides you with the lowest out-of-pocket costs.
Horizon Direct Access covers services provided by physicians and facilities outside of the RWJBarnabas Health Inner Circle. These are providers that participate in the Horizon Direct Access Network (in NJ) or the national BlueCard® network (outside NJ).
Out-of-network covers services provided by physicians and facilities that do not participate in the Horizon Direct Access network or the national BlueCard network.

Although not required, you are encouraged to select a Primary Care Physician (PCP) who assumes responsibility for coordinating your healthcare. It is recommended that you make an appointment to get your annual physical with your PCP — covered 100% in-network at no cost to you.

Deductible

	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Individual	$400	$1,000	$7,500
Family	$800	$2,000	$15,000

Member Coinsurance

	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Facility	No charge	You pay 30% after deductible	You pay 60% after deductible
Physician Office	You pay 20%; No deductible	You pay 30% after deductible	You pay 60% after deductible

Out-of-Pocket Maximum Expenses

	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Individual	$6,000	$8,700	$15,000
Family	$12,000	$17,400	$30,000

Preventive Care Services

	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Routine Adult Physical Exams 1 per calendar year	No charge	No charge	Not covered
Immunizations	No charge	No charge	Not covered
Routine Child Exams	No charge	No charge	Not covered
Routine GYN Exam	No charge	No charge	Not covered
Routine Mammogram	No charge	No charge	Not covered
Prostate Exam	No charge	No charge	Not covered

Office/Virtual Visits

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Primary Care Physician (PCP)	You pay 20%; no deductible	You pay 30% after deductible	You pay 60% after deductible
Specialist	You pay 20%; no deductible	You pay 30% after deductible	You pay 60% after deductible

TeleMed

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
TeleMed	$5 copay	$5 copay	$5 copay	$5 copay

Routine Eye Exam

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
One exam per 12 months for all ages	You pay 20%; no deductible	You pay 30%; no deductible	Not covered

Diagnostic X-rays/Radiology

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Facility	No charge	You pay 30% after deductible	You pay 60% after deductible
Physician Office	You pay 20%; no deductible	You pay 30% after deductible	You pay 60% after deductible

Diagnostic Lab

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Outpatient Facility and Freestanding Lab	No charge	You pay 30% after deductible	You pay 60% after deductible
Physician Office	You pay 20%; no deductible	You pay 30% after deductible	You pay 60% after deductible

Emergency Room Treatment/Urgent Care Center

Non-emergency use of the Emergency Room is not covered.

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Emergency Room Treatment	No charge after $125 copay, no deductible	No charge after $125 copay, no deductible	No charge after $125 copay, no deductible
Urgent Care Center	You pay 20%; no deductible	You pay 30% after deductible	You pay 60% after deductible

Inpatient Hospital Care/Inpatient Surgery

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Facility Charges	No charge	$1,000 copay then you pay 30% after deductible	$1,500 copay then you pay 60%
Professional/Physician Charges	You pay 20% after deductible	You pay 30% after deductible	You pay 60% after deductible

Outpatient Hospital Care/Outpatient Surgery

Service	Premier Tier/Inner Circle Tier	In-Network Tier	Out-of-Network Tier
Facility Charges	No charge	$1,000 copay then you pay 30% after deductible	$1,500 copay then you pay 60% after deductible
Professional/Physician Charges	You pay 20% after deductible	You pay 30% after deductible	You pay 60% after deductible

Medical Expenses Related to Automobile Accidents

For medical expenses related to an automobile accident, the RWJBarnabas Health medical plan pays as secondary coverage to the automobile insurance plan. It will be secondary even if a member declines their automobile insurance’s Personal Injury Protection (PIP) coverage. The RWJBarnabas Health plan will pay as if the automobile insurance PIP coverage had been in effect, and will carve-out that assumed benefit.

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.