PPO Plan

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

	In-Network	Out-of-Network
Individual	$2,500	$4,000
Family	$5,000	$8,000

Coinsurance

	In-Network	Out-of-Network
Coinsurance	80%	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	$5,000	$8,000
Family	$10,000	$16,000

Benefit Period Maximum

Unlimited

Lifetime Maximum

Unlimited

Primary Care Physician Selection

Unlimited

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 $60 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
80%, 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 80% afer deductible	Covered at 50% afer deductible
Outpatient Facility	$100 copay then covered at 80% after Deductible	Covered at 50% afer deductible

Hospital Care

	In-Network	Out-of-Network
Inpatient Admission (including maternity)	80%, deductible applies	50%, deductible applies
Room and Board	80%, deductible applies	50%, deductible applies
Pre-admission Testing	80%, deductible applies	50%, deductible applies
Surgery in Hospital	80%, deductible applies	50%, deductible applies
Inpatient Physician Services	80%, deductible applies	50%, deductible applies
Outpatient Department Services (Non-Surgical)	80%, 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	80%, no deductible	80%, no deductible

Outpatient Surgery

	In-Network	Out-of-Network
Hospital Outpatient Surgery	80%, deductible applies	50%, deductible applies
Surgery in an Ambulatory SurgiCenter	80%, deductible applies	50%, deductible applies

Mental Health 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	80%, deductible applies	50%, deductible applies
Outpatient Department	80%, deductible applies	50%, deductible applies
Office setting	100% after $60 copay	50%, deductible applies

Substance 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	80%, deductible applies	50%, deductible applies
Outpatient Department	80%, deductible applies	50%, deductible applies
Office setting	100% after $60 copay	50%, deductible applies

Alcohol Abuse Services

Inpatient and Outpatient Mental Health/Substance Abuse/Alcoholism Services must be coordinated through Horizon Behavioral Health at 1-800-626-2212.

Infertility

	In-Network	Out-of-Network
Inpatient	80%, deductible applies	50%, deductible applies
Outpatient Department	80%, deductible applies	50%, deductible applies
Office setting	100% after $60 copay	50%, deductible applies

	In-Network	Out-of-Network
Diagnosis and Treatment of underlying condition	80%, deductible applies	50%, deductible applies
Advanced Services such as In Vitro ($10k Lifetime Maximum)	80%, deductible applies	50%, deductible applies

Other Services

	In-Network	Out-of-Network
Bariatric Surgery	80%, deductible applies	50%, deductible applies
Diabetic Education	80%, deductible applies	50%, deductible applies
Diabetic Supplies	80%, deductible applies	50%, deductible applies
Durable Medical Equipment	80%, deductible applies	50%, deductible applies
Orthotics and Prosthetics	80%, deductible applies	50%, deductible applies
Home Health Care	80%, deductible applies	50%, deductible applies
Hospice Care	80%, deductible applies	50%, deductible applies
Physical Rehabilitation Facility Inpatient Services	80%, deductible applies	50%, deductible applies
Short-term Therapies Physical, Occupational, Speech, Respiratory	80%, deductible applies	50%, deductible applies
Private Duty Nursing	80%, deductible applies	50%, deductible applies
Skilled Nursing Facility/Extended Care Center Limited to 60 facility days per Benefit Period	80%, deductible applies	50%, deductible applies
Therapeutic Manipulation (Chiropractic Care)	80%, deductible applies	50%, deductible applies

Adult Vision

Vision hardware not covered

In-Network	Out-of-Network
100%, no deductible & no copay	50%, deductible applies & no copay

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).