Getting the Most From Your Benefits
Medical insurance can be difficult to understand. We want to make sure you understand your insurance so you get the most from your benefits.
Deductible, Copayments, Coinsurance and Out-of-Pocket Maximum
Understanding these terms will help you know when and how much you have to pay for care.
- A deductible is the amount of money you have to pay before medical insurance starts paying for medical treatment and services. For example, if your plan has a $500 deductible, you will have to pay $500 before insurance begins covering the cost of covered services.
- Copayment is the amount you pay each time you receive health care services, such as doctor visits or prescriptions drugs.
- Coinsurance is the percentage you pay for medical treatment or services after you have paid your deductible. For example, if your coinsurance is 10% and your medical procedure is $100, you would pay $10 and your insurance would pay the remaining $90.
- Out-of-pocket maximum is the most you have to pay each year toward medical services. Once your out-of-pocket maximum is reached, your insurance will pay for all covered services.
In-network versus out-of-network
Doctors, hospitals and other health care professionals who participate in Horizon BCBSNJ’s networks are in network. Check the Doctor & Hospital Finder to make sure your doctor, other health care professional, hospital and other medical facility are listed. In-network doctors, hospitals and other health care professionals have agreed to provide care at negotiated rates under your Horizon BCBSNJ plan.
When you choose an in-network doctor, other health care professional or facility, you pay less out of pocket, even if you have out-of-network benefits.
Out of network refers to doctors, hospitals and other health care professionals who do not participate with Horizon BCBSNJ. Even if you have out-of-network benefits, you may have a higher deductible, coinsurance and/or copayment. You may also have to pay the difference between the amount Horizon BCBSNJ pays for the service and the actual charge for the service. If you do not have out-of-network benefits, you are responsible for the cost of all services received out of network, unless it is an emergency.
Generic versus brand medicines
Generic medicines are approved by the U.S. Food and Drug Administration (FDA) and must work the same as the brand name medicine. Almost eight out of 10 prescriptions are now written for generic medicines. On average, the cost of a generic drug is 80 to 85 percent lower than the brand name product. When your doctor writes a prescription, ask if there is a generic version available. Generics cost less, so you will pay less out of your pocket.
Emergency Room (ER) care
When you have a medical emergency, go to the nearest ER. But when your illness or injury is not severe and your doctor is not available, consider going to an urgent care center or retail health center for treatment. Both are equipped to handle basic urgent and minor illnesses and injuries quickly, and at a fraction of the cost and time of the ER.
Use our Doctor & Hospital Finder to look for a participating urgent care center or retail health center near you. Note that routine care, such as physicals, immunizations and physical therapy, are not covered at urgent care centers or retail health centers.
Identity Protection Service
At Horizon BCBSNJ, we believe personal information should stay that way—personal. That’s why we offer SHBP/SEHBP members automatic free access to AllClear Identity Repair™, a comprehensive identity protection service. AllClear Credit Monitoring™ is also available at no cost, but you must enroll in this coverage directly with AllClear ID. Visit HorizonBlue.AllClearID.com to access identity protection services. By accessing this link, you confirm that you are eligible for these services and you agree that identity protection services will be cancelled if you are not eligible.