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Plan Type EPO
Office Visit for Primary Doctor
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$30 Copay
Office Visit for Specialist $30 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible None
Separate Prescription Drugs Deductible None
Coinsurance None
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit $0
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Emergency Care Only.
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge, covered up to $600 per covered person per calendar year.
Periodic OB-GYN Exam No Charge, covered up to $600 per covered person per calendar year.
Well Baby Care No Charge, covered up to $600 per covered person per calendar year.
Emergency and Urgent Care
Emergency Room $100 Copay (waived if admitted)
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs N/A
Mail Order Supply 30
Outpatient Coverage
Outpatient Surgery $250 Copay
Outpatient Lab/X-Ray $500 maximum per covered person per calendar year.**
**For diagnostic services rendered in the office, freestanding or an outpatient facility.
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization $500 copayment per covered person per period of confinement (90 days per covered person per calendar year)
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit 30 Copay of initial visit, Limitations on Outpatient Lab/ X-Ray applies to maternity related Lab/ X-Ray performed during pre & postnatal care
Labor & Delivery Hospital Stay $500 copayment per period of confinement (90 days per covered person per calendar year)
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required Yes
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating NR-5 as of 06/23/2010
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Summary of Benefits & Coverage

The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

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Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • Horizon Blue Cross Blue Shield of New Jersey - Horizon Blue Cross Blue Shield of New Jersey works with independent agencies authorized to sell health plans in New Jersey through Horizon Healthcare of New Jersey, Inc. and Horizon Blue Cross Blue Shield of New Jersey.