OMNIA℠ Health Plan for RWJBH BHealthy Care
You and your family can receive care AT NO COST from Premier providers if you are enrolled in the OMNIA Plan! Our network of Premier providers is expanding and includes all RWJBH providers, facilities, and many other affiliated groups. Copay will apply for Emergency Room visits.
The OMNIA Health Plan offers you the benefits of patient-centered care with access to all of the healthcare professionals in the Horizon Managed Care Network. Coverage levels vary depending upon what providers are used.
- Premier Tier: There is generally no cost to you when you use RWJBH hospitals and labs, the Medical Group, and Joint Venture facility and physician groups of RWJBH.
- Inner Circle Tier: The Inner Circle Tier includes providers that are affiliated with the RWJBH healthcare system — doctors that have admitting privileges and work closely with RWJBH but are not employed by RWJBH.
- OMNIA Tier 1: Your out-of-pocket expenses for using OMNIA Tier 1 providers are higher than the Premier or Inner Circle tiers.
- OMNIA Tier 2: Your out-of-pocket expenses for using OMNIA Tier 2 providers are the highest of all tiers. Tier 2 includes all providers and facilities in the Horizon Network, along with the National BlueCard® network for coverage outside of New Jersey.
NOTE THAT THERE IS NO OUT-OF-NETWORK COVERAGE, EXCEPT IN THE CASE OF AN EMERGENCY.
Deductible
Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
|
---|---|---|---|---|
Individual | None | None | $2,500 | $5,000 |
Family | None | None | $5,000 | $10,000 |
Member Coinsurance
Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
|
---|---|---|---|---|
Your Payment | No charge | No charge | You pay 50% after deductible | You pay 60% after deductible |
Out-of-Pocket Maximum Expenses
- Includes medical and prescription drug deductible, coinsurance and copays
- All out-of-pocket expenses accrued under any tier will accumulate across all out-of-pocket maximum tiers.
Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
|
---|---|---|---|---|
Individual | $2,500 | $2,500 | $8,700 | $8,700 |
Family | $5,000 | $5,000 | $17,400 | $17,400 |
Preventive Care Services
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Routine Adult Physical Exams 1 per calendar year |
No Charge | No Charge | No Charge | No Charge |
Immunizations | No Charge | No Charge | No Charge | No Charge |
Routine Child Exams | No Charge | No Charge | No Charge | No Charge |
Routine GYN Exam | No Charge | No Charge | No Charge | No Charge |
Routine Mammogram | No Charge | No Charge | No Charge | No Charge |
Prostate Exam | No Charge | No Charge | No Charge | No Charge |
Office/Virtual Visits
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Primary Care Physician (PCP) | No Charge | $20 copay | $40 copay | $50 copay |
Specialist | No Charge | $40 copay | $80 copay | $100 copay |
TeleMed for Urgent Care
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
TeleMed for Urgent Care | $5 copay | $5 copay | $5 copay | $5 copay |
Routine Eye Exam
One exam per 12 months for all ages.
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Routine Eye Exam | No Charge | No Charge | No Charge | No Charge |
Diagnostic X-rays/Radiology
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Outpatient Facility | No Charge | No Charge | You pay 50% after deductible | You pay 60% after deductible |
Physician Office | No Charge | No Charge | No Charge | No Charge |
Diagnostic Lab
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Physician Office, LabCorp or Quest Lab | No Charge | No Charge | No Charge | No Charge |
Outpatient Facility | No Charge | No Charge | $80 copay | $100 copay |
LabCorp and Quest are the preferred Independent Lab partners for Horizon.
Emergency Room Treatment/Urgent Care Center
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Emergency Room Treatment | No charge after $125 facility copay, no deductible. Non-emergency use of the Emergency Room is not covered. | |||
Urgent Care Center | No Charge | $50 copay | $100 copay | $100 copay |
Inpatient Facility/Professional/Physician Charges
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Facility Charges | No charge at RWJBH Facilities | No charge at RWJBH Facilities | $1,500 copay per admission then you pay 50% after deductible | You pay 60% after deductible |
Professional/Physician Charges | No Charge | No Charge | You pay 50% after deductible | You pay 60% after deductible |
Outpatient Facility/Professional/Physician Charges
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Facility Charges | No charge | $300 copay | $1,500 copay per admission then you pay 50% after deductible | You pay 60% after deductible |
Professional/Physician Charges | No Charge | No Charge | You pay 50% after deductible | You pay 60% after deductible |
Short-Term Therapies (Speech/Physical/Occupational)
30 visit maximum PER therapy, PER condition, PER incident.
Service | Premier Tier | Inner Circle Tier | OMNIA Tier 1 | OMNIA Tier 2 Includes BlueCard® outside of NJ |
---|---|---|---|---|
Physical Therapy | No Charge | $30 copay | $50 copay | $75 copay |
Speech & Occupational Therapy Visit limit doesn't apply to autism related diagnoses. |
No Charge | $20 copay | $40 copay | $50 copay |