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 |
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.