OMNIA℠ #12 HSA
Please note that the benefit highlights are provided for informational purposes. Horizon BCBSNJ makes every effort to provide clear and accurate information pertaining to these benefit highlights. However, because Horizon BCBSNJ generally expects continued guidance from regulators on issues pertaining to Federal health care reform, the information that has been provided is subject to change. Horizon BCBSNJ will provide notice of such changes to members pursuant to State and Federal requirements.
This summary highlights the major features of your health benefit program. It is not a contract and some limitations and exclusions may apply. Payment of benefits is subject solely to the terms of the contract. Please refer to your benefit booklet for more information.
- The benefit period is a calendar year.
- There is no out-of-network coverage with this plan.
Deductible
The deductible is per calendar year.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Individual | $2,000 | $2,500 |
| Family | $4,000 | $5,000 |
Coinsurance
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Coinsurance | 80% | 50% |
Maximum Out of Pocket (MOOP)
Tier 1 Ded/MOOP accumulates to Tier 2 Ded/MOOP but Tier 2 Ded/MOOP does not accumulate to Tier 1 Ded/MOOP. Once Tier 2 Ded/MOOP has been met, Tier 1 will also have been met.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Individual | $4,500 | $6,650 |
| Family | $9,000 | $13,300 |
Benefit Period Maximum
Unlimited
Lifetime Maximum
Unlimited
Primary Care Physician Selection
Not Required
Primary Care Office Visit
Primary Care Providers is defined as Family Practitioner, Internist, OB/GYN, Pediatrician, General Practitioner.
| OMNIA Tier 1 | OMNIA Tier 2 |
| $20 copay after deductible | $40 copay after deductible |
Specialist Office Visit
A referral is not required to visit a specialist.
| OMNIA Tier 1 | OMNIA Tier 2 |
| $40 copay after deductible | $50 copay after deductible |
Maternity Visits
Dependent children are eligible for maternity/obstetrical benefits. Copay applies to 1st visit only.
| OMNIA Tier 1 | OMNIA Tier 2 |
| $40 copay after deductible | $50 copay after deductible |
Allergy Testing and Treatment
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Office Setting Copay only applies to office visit if billed. |
100% in office setting | 100% in office setting |
| Outpatient Facility | 80%, after deductible% | 50%, after deductible |
Preventive Care
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Routine Adult Physicals, GYN Exams, PAP, Mammograms, Prostate Cancer Screening, Colorectal Screening, Immunizations | 100% | 100% |
| Well Child Exams | 100% | 100% |
| Well Child Immunizations and Lead Screening | 100% | 100% |
| Routine Laboratory | 100% in office Quest, LabCorp & SMG | 100% in office Quest, LabCorp & SMG |
| Diagnostic | 80% after deductible outpatient facility | 50% after deductible outpatient facility |
X-ray/Radiology Services
Routine X-ray/Radiology Services
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Office | Covered at 100% | Covered at 100% |
| Freestanding Facility | Covered at 100% | Covered at 100% |
| Outpatient Facility | Covered at 100% | Covered at 100% |
Non-Routine/Diagnostic X-ray/Radiology Services
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Office | 100% after deductible in office | 100% after deductible in office |
| Freestanding Facility | 80% afer deductible | 50% afer deductible |
| Outpatient Facility | 80% after deductible | 50% afer deductible |
Hospital Care
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient Admission (including maternity) | 80% after deductible | 50% after deductible |
| Room and Board | 80% after deductible | 50% after deductible |
| Pre-admission Testing | 80% after deductible | 50% after deductible |
| Surgery in Hospital | 80% after deductible | 50% after deductible |
| Inpatient Physician Services | 80% after deductible | 50% after deductible |
| Outpatient Department Services (Non-Surgical) | 80% after deductible | 50% after deductible |
Emergency Care
Payment at the in-network level across-the-board applies only to true Medical Emergencies & Accidental Injuries.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Emergency Room | $100 facility copay then deductible then 80% | $100 facility copay then deductible then 80% |
| Ambulance | 100% after Tier 1 deductible | 100% after Tier 1 deductible |
Outpatient Surgery
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Hospital Outpatient Surgery | 80% after deductible | 50% after deductible |
| Surgery in an Ambulatory SurgiCenter | 80% after deductible | 50% after deductible |
Mental Health Services
Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient | 80% after deductible | 50% after deductible |
| Outpatient Department | 80% after deductible | 50% after deductible |
| Office setting | $40 copay after deductible | $50 copay after deductible |
Substance Abuse Services
Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient | 80% after deductible | 50% after deductible |
| Outpatient Department | 80% after deductible | 50% after deductible |
| Office setting | $40 copay after deductible | $50 copay after deductible |
Alcohol Abuse Services
Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Inpatient | 80% after deductible | 50% after deductible |
| Outpatient Department | 80% after deductible | 50% after deductible |
| Office setting | $40 copay after deductible | $50 copay after deductible |
Infertility
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Diagnosis and Treatment of underlying condition | $40 copay after deductible office visit or 80% after decutible outpatient facility | $50 copay after deductible office visit or 50% after decutible outpatient facility |
| Advanced Services such as In Vitro ($10k Lifetime Maximum) | Not Covered | Not Covered |
Other Services
| OMNIA Tier 1 | OMNIA Tier 2 | |
| Bariatric Surgery | 80% after deductible | 50% after deductible |
| Diabetic Education | office copayment after deductible | office copayment after deductible |
| Diabetic Supplies | 80% after deductible | 50% after deductible |
| Durable Medical Equipment | 80% after deductible | 50% after deductible |
| Orthotics and Prosthetics | $20 copay after deductible | $40 copay after deductible |
| Home Health Care | $20 copay after deductible | $40 copay after deductible |
| Hospice Care | 80% after deductible | 50% after deductible |
| Physical Rehabilitation Facility Inpatient Services | 80% after deductible | 50% after deductible |
| Short-term Therapies Physical, Occupational, Speech, Respiratory 30 visit maximum per therapy, per benefit period |
$20 copay after deductible 80% after deductible in outpatient facility |
$30 copay after deductible 50% after deductible in outpatient facility |
| Private Duty Nursing Limited to 30 visits per benefit period (8-hour shifts) |
100% | 80% after deductible |
| Skilled Nursing Facility/Extended Care Center Limited to 100 days per benefit period |
80% after deductible | 50% after deductible |
| Therapeutic Manipulation (Chiropractic Care) 25 visit maximum per benefit period |
$30 copay after deductible | $30 copay after deductible |
Adult Vision
Vision hardware not covered
| OMNIA Tier 1 | OMNIA Tier 2 |
| Not Covered | Not Covered |
Pediatric Vision
$150 Hardware Allowance for dependent children under age 15.
| OMNIA Tier 1 | OMNIA Tier 2 |
| 100% | 100% |
Telemedicine Services
| OMNIA Tier 1 | OMNIA Tier 2 |
| 100% after $10 copay after deductible, per visit | 100% after $10 copay after deductible, per visit |
Prescription Drugs
| Retail | Mail Order | |
| Generic | $10 Copay (30 day supply), after deductible | $20 Copay (90 day supply), after deductible |
| Preferred Brand | $50 Copay (30 day supply), after deductible | $100 Copay (90 day supply), after deductible |
| Non-Preferred Brand | $75 Copay (30 day supply), after deductible | $225 Copay (90 day supply), after deductible |
Eligibility
Dependent children, including full-time students are covered until the end of the month in which they reach the age of 26. Handicapped dependents are covered beyond the child removal age, if the handicap occurred prior to the age of 26. Under certain conditions, coverage may be extended for qualified dependents up to age 31. Please refer to your benefit booklet for further information as this benefit highlight is not an exhaustive list.
Pre-Existing Conditions
Not Applicable
Prior Authorization
Some services/procedures require prior authorization. For a complete list, contact our customer service number at 1-800-355-BLUE (2583).
