Enhanced PPO
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.
Deductible
The deductible is per calendar year.
| In-Network | Out-of-Network | |
| Individual | $2,000 | $4,000 |
| Family | $4,000 | $8,000 |
Coinsurance
| In-Network | Out-of-Network | |
| Coinsurance | 90% | 50% |
Maximum Out of Pocket (MOOP)
Consolidated Maximum Out of Pocket is Calendar Year. The deductible, coinsurance, prescription, and copayments apply to the Maximum Out of Pocket.
| In-Network | Out-of-Network | |
| Individual | $4,000 | $8,000 |
| Family | $8,000 | $16,000 |
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.
| In-Network | Out-of-Network |
| 100% after $30 copay | 50%, deductible applies |
Specialist Office Visit
A referral is not required to visit a specialist.
| In-Network | Out-of-Network |
| 100% after $50 copay | 50%, deductible applies |
Maternity Visits
Dependent children are eligible for maternity/obstetrical benefits. Copay applies to 1st visit only.
| In-Network | Out-of-Network |
| 100%, no deductible & no copay | 50%, deductible applies |
Allergy Testing and Treatment
| In-Network | Out-of-Network |
| 90%, no deductible & no copay | 50%, deductible applies |
Preventive Care
| In-Network | Out-of-Network | |
| Routine Adult Physicals, GYN Exams, PAP, Mammograms, Prostate Cancer Screening, Colorectal Screening, Immunizations | 100%, no deductible & no copay | 50%, deductible applies & no copay |
| Well Child Exams | 100%, no deductible & no copay | 50%, deductible applies & no copay |
| Well Child Immunizations and Lead Screening | 100%, no deductible & no copay | 50%, deductible applies & no copay |
| Routine Laboratory | 100%, no deductible & no copay | 50%, deductible applies, no copay |
X-ray/Radiology Services
Routine X-ray/Radiology Services
| In-Network | Out-of-Network | |
| Office | Covered at 100% | Covered at 50% afer deductible |
| Freestanding Facility | Covered at 100% | Covered at 50% afer deductible |
| Outpatient Facility | Covered at 100% | Covered at 50% afer deductible |
Non-Routine/Diagnostic X-ray/Radiology Services
| In-Network | Out-of-Network | |
| Office | Covered at 100% after applicable copay. The copay only applies to the office visit charge. | Covered at 50% afer deductible |
| Freestanding Facility | Covered at 90% afer deductible | Covered at 50% afer deductible |
| Outpatient Facility | $100 copay then covered at 90% after Deductible | Covered at 50% afer deductible |
Hospital Care
| In-Network | Out-of-Network | |
| Inpatient Admission (including maternity) | 90%, deductible applies | 50%, deductible applies |
| Room and Board | 90%, deductible applies | 50%, deductible applies |
| Pre-admission Testing | 90%, deductible applies | 50%, deductible applies |
| Surgery in Hospital | 90%, deductible applies | 50%, deductible applies |
| Inpatient Physician Services | 90%, deductible applies | 50%, deductible applies |
| Outpatient Department Services (Non-Surgical) | 90%, deductible applies | 50%, deductible applies |
Emergency Care
Payment at the in-network level across-the-board applies only to true Medical Emergencies & Accidental Injuries.
| In-Network | Out-of-Network | |
| Emergency Room | 100% after $200 copay | 100% after $200 copay |
| Ambulance | 90%, no deductible | 90%, no deductible |
Outpatient Surgery
| In-Network | Out-of-Network | |
| Hospital Outpatient Surgery | 90%, deductible applies | 50%, deductible applies |
| Surgery in an Ambulatory SurgiCenter | 90%, deductible applies | 50%, deductible applies |
Mental Health/Substance Abuse/Alcohol Abuse Services
Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.
| In-Network | Out-of-Network | |
| Inpatient | 90%, deductible applies | 50%, deductible applies |
| Outpatient Department | 90%, deductible applies | 50%, deductible applies |
| Office setting | 100% after $50 copay | 50%, deductible applies |
Infertility
| In-Network | Out-of-Network | |
| Diagnosis and Treatment of underlying condition | 90%, deductible applies | 50%, deductible applies |
| Advanced Services such as In Vitro ($10k Lifetime Maximum) | 90%, deductible applies | 50%, deductible applies |
Other Services
| In-Network | Out-of-Network | |
| Bariatric Surgery | 90%, deductible applies | 50%, deductible applies |
| Diabetic Education | 90%, deductible applies | 50%, deductible applies |
| Diabetic Supplies | 90%, deductible applies | 50%, deductible applies |
| Durable Medical Equipment | 90%, deductible applies | 50%, deductible applies |
| Orthotics and Prosthetics | 90%, deductible applies | 50%, deductible applies |
| Home Health Care | 90%, deductible applies | 50%, deductible applies |
| Hospice Care | 90%, deductible applies | 50%, deductible applies |
| Physical Rehabilitation Facility Inpatient Services | 90%, deductible applies | 50%, deductible applies |
| Short-term Therapies Physical, Occupational, Speech, Respiratory |
90%, deductible applies | 50%, deductible applies |
| Private Duty Nursing | 90%, deductible applies | 50%, deductible applies |
| Skilled Nursing Facility/Extended Care Center Limited to 60 facility days per Benefit Period |
90%, deductible applies | 50%, deductible applies |
| Therapeutic Manipulation (Chiropractic Care) |
90%, deductible applies | 50%, deductible applies |
Adult & Pediatric Vision
Vision hardware not covered
| In-Network | Out-of-Network |
| 100%, no deductible & no copay | 50%, deductible applies & no copay |
Telemedicine Services
| In-Network | Out-of-Network |
| 100% after $20 copay, per visit | N/A |
Prescription Drugs
| Retail | Mail Order | |
| Generic | $10 Copay (30 day supply) | $20 Copay (90 day supply) |
| Preferred Brand | $50 Copay (30 day supply) | $100 Copay (90 day supply) |
| Non-Preferred Brand | $75 Copay (30 day supply) | $225 Copay (90 day supply) |
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).
