OMNIA℠ Health Plan for RWJBH BHealthy Care

You and your family can receive care AT NO COST from Domestic providers if you are enrolled in the OMNIA Plan! Our network of Domestic 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.

Domestic 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 Domestic 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

	Domestic 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

	Domestic 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.

	Domestic 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	Domestic 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	Domestic 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	Domestic 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	Domestic 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	Domestic 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	Domestic 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	Domestic 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	Domestic 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	Domestic 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	Domestic 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

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.