Horizon HMO
Check with your employer to find out if this plan is available to you.
With our HMO plan, you have access to health care professionals and facilities in the Horizon Managed Care Network in New Jersey and parts of New York, Pennsylvania and Delaware. You select a licensed Primary Care Physician from the Horizon Managed Care Network as your Primary Care Physician (PCP), and your PCP will refer you to specialty care when needed. In addition, the Away From Home Care Program is available to eligible HMO members who will be outside the state of New Jersey, like students living away from home, long-term travelers and families living apart.
IN-NETWORK (IN)
| Service Area Available | NJ and contiguous counties |
| Specialist Referral | Referral required |
| Deductible Deductible applies to all services that require a coinsurance. |
|
| See DME | |
| See DME | |
| Coinsurance | 0% |
| Coinsurance Out-of-Pocket Maximum | |
| Not applicable | |
| Not applicable | |
| Total Out-of-Pocket Maximum (Copay+Deductible+Coinsurance) | |
| $7,280 | |
| $14,560 | |
HEALTH CARE SERVICES
| Primary Care Office Visit | $10 |
| Annual Routine Physical (In-Network Only) | $0 |
| Direct Primary Care (DPC) | Not available |
| First Responders Docs (FRDOCS) | $0 |
| Horizon CareOnline (Telemedicine) | Cost share may apply |
| Specialist Office Visit | $10 |
| Annual Routine Vision (In-Network Only) | $10 |
| Chiropractic 20 visits per calendar year |
$10 |
| Physical/Occupational/Speech Therapy 60 visit combined maximum per calendar year |
$10 |
DIAGNOSTIC LABORATORY/RADIOLOGY/ADVANCED IMAGING
| Outpatient Laboratory/Radiology/Advanced Imaging | $0 |
| Freestanding Laboratory/Radiology/Advanced Imaging | $0 |
EMERGENCY/URGENT MEDICAL SERVICES
| Urgent Care Center | $10 referral required |
| Emergency Room | $85* |
| Ambulance | $0 |
OTHER SERVICES
| Inpatient Facility | $0 |
| Outpatient Facility | $0 |
| Outpatient Behavioral Health | $10 |
| Durable Medical Equipment (DME) | $100 deductible, then covered in full |
OUT-OF-NETWORK (OON)
No out-of-network benefits
This document is for informational purposes only and does not constitute a binding agreement. The information provided by this document is not intended to replace or modify the terms, conditions, limitations and exclusions contained within health, dental or vision benefit plans issued or administered by Horizon BCBSNJ. In the event of a conflict between the information contained in this document and your plan documents, your plan documents shall control.
Retirees: Please visit state.nj.us/treasury/pensions for information regarding available retiree plans.
This is not a complete list of all covered services. Exclusions and limitations apply to some services. Visit state.nj.us/treasury/pensions/member-guidebooks.shtml for more information.
