Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Coverage Period: 01/01/2020 - 12/31/2020
Horizon BCBSNJ: Direct Access Platinum
Coverage for: All Coverage Types
Plan Type: DA
(G3968/P2128)
(G3969/P2128)
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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the
plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will
be provided separately. This is only a summary. Benefits may change upon renewal. For more information about your coverage, or to get a
copy of the complete terms of coverage, visit Member Online Services at www.HorizonBlue.com/members or by calling 1-800-355-
BLUE(2583). If you do not currently have coverage with Horizon BCBSNJ you can view a sample policy here,
http://www.state.nj.us/dobi/division_insurance/ihcseh/sehforms.html. For general definitions of common terms, such as allowed amount,
balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at
www.cciio.cms.gov or call 1-800-355-BLUE (2583) to request a copy.
Answers
Why This Matters:
What is the overall
deductible
?
$1,500.00/Individual or
$3,000.00/Family for out-of-network
providers.
Generally, you must pay all of the costs from
providers up to the deductible amount
before this plan begins to p
ay. If you have other family members on the plan, each
family member must meet their own individual
deductible until the total amount of
deductible
expenses paid by all family members meets the overall family deductible.
Are there services covered
before you meet your
deductible
?
Yes. Preventive care is covered before
you meet your deductible.
This plan covers some items and services even if you haven’t yet met the deductible
amount. But a
copayment or coinsurance may apply. For example, this plan covers
certain
preventive services without cost-sharing and before you meet your deductible
.
See a list of covered
preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles
for specific services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit
for this plan?
Yes, For in-network Health/Pharmacy
providers $3,000.00 Individual/
$6,000.00 Family. For out-of-
network Health providers $6,000.00
Individual/$12,000.00 Family.
Aggregate family.
The out-of-pocket limit is the most you could pay in a year for covered services. If
you have other family members in this
plan, they have to meet their own out-of-
pocket limits
until the overall family out-of pocket limit has been met.
What is not included in the
out
-of-pocket limit?
Premiums, penalties for failure to
obtain pre-authorization for services,
balance-billing
charges and health care
this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out–of–pocket
limit
.
Will you pay less if you use
a
network provider?
Yes. For a list of in-network
providers, see
www.HorizonBlue.com or call 1-
800-355-BLUE (2583).
Benefits provided by in-network
providers and BlueCard PPO
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network
. You will pay the most if you use an out-of-network provider
, and you might
receive a bill from a
provider for the difference between the provider’s charge and
what your
plan pays (balance billing). Be aware your network provider might use an
out
-of-network provider for some services (such as lab work). Check with your
provider
before you get services.
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providers are at the in-network level
of benefits.
Do you need a referral to
see a specialist?
No. You don't need a referral to see a
specialist.
You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the
least)
Out-of-Network
Provider
(You will pay
the most)
If you visit a health
care
provider’s office
or clinic
Primary care visit to treat an
injury or illness
$20.00 Copayment per
visit. $15.00 Copayment
per visit applies only to
Horizon CareOnline.
30% Coinsurance.
Network benefit applies to selected
Network PCP.
Specialist visit
$40.00 Copayment per
visit. $15.00 Copayment
per visit applies only to
Horizon CareOnline.
30% Coinsurance.
Network benefit applies to non-selected
Network PCP.
Preventive
care
/screening/immunization
No Charge.
No Charge. Deductible
does not apply.
One per calendar year. You may have
to pay for services that aren't
preventive. Ask your provider if the
services needed are preventive. Then
check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood
work)
No Charge for Office,
Independent Laboratory,
Outpatient Hospital.
30% Coinsurance for
Office, Independent
Laboratory, Outpatient
Hospital.
Molecular and genomic testing are
subject to pre-service and post-service
medical necessity review.
Imaging (CT/PET scans, MRIs)
No Charge for Outpatient
Facility.
30% Coinsurance for
Outpatient Facility.
Requires pre-approval; 50% penalty
applies for non-compliance.
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage
is available at
Prime Therapeutics
LLC (Prime) Service
Center
www.MyPrime.com
or 1
-800-370-5088.
Generic drugs
$10.00 Copayment/Retail;
$20.00 Copayment/Mail
Order.
$10.00 Copayment/Retail;
$20.00 Copayment/Mail
Order. Deductible
does not
apply.
Prior authorization may be required.
Covers up to a 30 day supply per
copayment, up to a 90 day supply
applying separate copayments (retail)
and a 90 day supply (mail order).
Preferred brand drugs
$25.00 Copayment/Retail;
$50.00 Copayment/Mail
Order.
$25.00 Copayment/Retail;
$50.00 Copayment/Mail
Order. Deductible
does not
apply.
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Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the
least)
Out-of-Network
Provider
(You will pay
the most)
View the formulary at
https://www.myprime.c
om/content/dam/prim
e/memberportal/forms
/AuthorForms/HIM/2
020/2020_NJ_3T_Heal
thInsuranceMarketplace
ClassicDL.pdf
Non-preferred brand drugs
$50.00 Copayment/Retail;
$100.00 Copayment/Mail
Order.
$50.00 Copayment/Retail;
$100.00 Copayment/Mail
Order. Deductible
does not
apply.
Specialty drugs
Covered at retail benefit in
above applicable categories.
Covered at retail benefit in
above applicable categories.
If you have
outpatient surgery
Facility fee (e.g., ambulatory
surgery center)
$150.00 Copayment per
visit for Ambulatory
Surgical Center,
Outpatient
Hospital.
30% Coinsurance for
Outpatient Hospital,
Ambulatory Surgical
Center.
Procedures related to spine surgery are
subject to pre-service and post-service
utilization management review.
Physician/surgeon fees
No Charge for Outpatient
Hospital, Ambulatory
Surgical Center.
30% Coinsurance for
Outpatient Hospital,
Ambulatory Surgical
Center.
Procedures related to spine surgery are
subject to pre-service and post-service
utilization management review. 30%
Coinsurance for out-of-network
anesthesia.
If you need
immediate medical
attention
Emergency room care
$100.00 Copayment per
visit for Outpatient
Hospital.
$100.00 Copayment per
visit for Outpatient
Hospital. Deductible does
not apply.
Copayment waived if admitted within
24 hours. Out-of-network payment at
the in-network level of benefits applies
only to true medical emergencies and
accidental injuries.
Emergency medical
transportation
No Charge.
No Charge.
Deductible does not apply.
Urgent care
$75.00 Copayment.
$75.00 Copayment.
Deductible does not apply.
No coverage for non-urgent care.
If you have a
hospital stay
Facility fee (e.g., hospital room)
$250.00 Copayment per
day for Inpatient Hospital.
30% Coinsurance for
Inpatient Hospital.
Requires pre-approval; 50% penalty
applies for non-compliance. In-
network
inpatient separation period is limited to
90 days. $1,250.00 copayment
maximum per admission.
Physician/surgeon fees
No Charge for Inpatient
Hospital.
30% Coinsurance for
Inpatient Hospital after
deductible.
30% Coinsurance for out-of-network
anesthesia.
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services
No Charge for Outpatient
Hospital.
30% Coinsurance for
Outpatient Hospital.
__________none__________
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Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the
least)
Out-of-Network
Provider
(You will pay
the most)
Inpatient services
$250.00 Copayment per
day for Inpatient Hospital.
30% Coinsurance for
Inpatient Hospital.
Requires pre-approval; 50% penalty
applies for non-compliance. In-
network inpatient separation period is
limited to 90 days. $1,250.00
copayment maximum per admission.
If you are pregnant
Office visits
$20.00 Copayment per visit
for Office. $40.00
Copayment per visit for
Specialist.
30% Coinsurance for
Office.
Cost sharing does not apply for
preventive services. Maternity care may
include tests and services described
elsewhere in the SBC (i.e. Ultrasound.)
Childbirth/delivery professional
services
No Charge for Inpatient
Hospital.
30% Coinsurance for
Inpatient Hospital.
__________none__________
Childbirth/delivery facility
services
$250.00 Copayment per
day for Inpatient Hospital.
30% Coinsurance for
Inpatient Hospital.
In-network inpatient separation period
is limited to 90 days. $1,250.00
copayment maximum per admission.
If you need help
recovering or have
other special health
needs
Home health care
$20.00 Copayment per visit
for Outpatient Facility.
30% Coinsurance for
Outpatient Facility.
Requires pre-approval; 50% penalty
applies for non-compliance. Private-
duty nursing is only covered under the
Home health care benefit when
required by a Home health care plan.
Coverage is limited to 60 visits per
calendar year.
Rehabilitation services
$250.00 Copayment per
day for Inpatient Hospital.
30% Coinsurance for
Inpatient Hospital.
Requires pre-approval; 50% penalty
applies for non-compliance. In-
network inpatient separation period is
limited to 90 days. $1,250.00
copayment maximum per admission.
Habilitation services
$250.00 Copayment per
day for Inpatient Hospital.
30% Coinsurance for
Inpatient Hospital.
Skilled nursing care
No charge for Inpatient
Facility.
30% Coinsurance for
Inpatient Facility.
Requires pre-approval; 50% penalty
applies for non-compliance.
Durable medical equipment
50% Coinsurance.
50% Coinsurance.
Hospice services
No Charge for Inpatient
Facility.
30% Coinsurance for
Inpatient Facility.
If your child needs
dental or eye care
Children’s eye exam
No Charge.
Not Covered.
This benefit is administered by Davis
Vision. In-
network routine vision exam
is limited to 1 visit.
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Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the
least)
Out-of-Network
Provider
(You will pay
the most)
Children’s glasses
Amounts greater than
$150.00 for non-collection
frames.
Not Covered.
This benefit is administered by Davis
Vision. Lenses and Hardware are
covered once every 12 months. Limit
includes 1 pair of frames from the
select Davis Vision collection or
$150.00 allowance for non-collection
frames.
Children’s dental check-up
Not Covered.
Not Covered.
__________none__________
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded
services.)
• Cosmetic Surgery
• Dental care (Adult)
• Hearing Aids (Only covered for Members
age 15 and younger)
• Long-term care
• Private-duty nursing
• Routine eye care (Adult,
Optometrist/Ophthalmologist office. For
verification of coverage on routine vision
services, please see your policy or plan
document.)
• Routine foot care
• Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
•
Acupuncture when used as a substitute for
other forms or anesthesia
• Bariatric surgery
• Chiropractic care
• Infertility treatment (limited to artificial
insemination; requires pre-approval)
• Most coverage provided outside the
United States. See www.HorizonBlue.com
• Non-emergency care when traveling
outside the U.S. See
www.HorizonBlue.com
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Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor's
Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to
you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit
www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more
information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete
information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: 1-800-355-BLUE (2583) or visit www.Horizonblue.com. You may also contact the Department of Labor’s Employee Benefits Security
Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. You may also contact the NJ Department of Banking and Insurance
Consumer Protection Services at 1-888-393-1062 ext 50998.
Does this plan provide Minimum Essential Coverage? Yes
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an
exemption from the requirement that you have health coverage for that month.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
-----------------------------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.---------------------------------------------
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will
be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost
sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare
the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care
and a hospital delivery)
■
The plan’s overall deductible
$0.00
■
Specialist
Copayment
$40.00
■
Hospital (facility)
Coinsurance
0%
■
Other
Coinsurance
0%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost
$12,800.00
In this example, Peg would pay:
Cost Sharing
Deductibles
$0.00
Copayments
$1,010.00
Coinsurance
$0.00
What isn’t covered
Limits or exclusions
$60.00
The total Peg would pay is
$1,070.00
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a
well-controlled condition)
■
The plan’s overall deductible
$0.00
■
Specialist
Copayment
$40.00
■
Hospital (facility)
Coinsurance
0%
■
Other
Coinsurance
50%
This EXAMPLE event includes services like:
Primary care physician office visits (
including disease
education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost
$7,400.00
In this example, Joe would pay:
Cost Sharing
Deductibles
$0.00
Copayments
$1,215.00
Coinsurance
$.00
What isn’t covered
Limits or exclusions
$55.00
The total Joe would pay is
$1,270.00
Mia’s Simple Fracture
(in-network emergency room visit and
follow up care)
■
The plan’s overall deductible
$0.00
■
Specialist
Copayment
$40.00
■
Hospital (facility)
Coinsurance
0%
■
Other
Coinsurance
50%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$1,900.00
In this example, Mia would pay:
Cost Sharing
Deductibles
$0.00
Copayments
$200.00
Coinsurance
$18.00
What isn’t covered
Limits or exclusions
$0.00
The total Mia would pay is
$218.00
The plan would be responsible for the other costs of these EXAMPLE covered services.
Notice of Nondiscrimination
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and does not discriminate against nor does it exclude people or treat
them differently on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the
administration of the plan, including enrollment and benefit determinations. Horizon BCBSNJ provides free aids and services to people with disabilities (e.g. qualified
sign language interpreters and information in other formats) and to those whose primary language is not English (e.g. information in other languages) to
communicate effectively with us.
Contacting Member Services
Please call Member Services at 1-800-355-BLUE (2583) (TTY 711) or the phone number on the back of your member ID card, if you need the free aids and services
noted above and for all other Member Services issues.
Filing a Section 1557 Grievance
If you believe that Horizon BCBSNJ has failed to provide the free communication aids and services or discriminated against you for one of the reasons described above,
you can file a discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ’s Civil Rights Coordinator can be reached by calling the Member
Services number on the back of your member ID card or by writing to the following address: Horizon BCBSNJ
Civil Rights Coordinator
PO Box 820, Newark, NJ 07101.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, through the Office for Civil Rights Complaint
Portal, online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW,
Room 509F, HHH Building, Washington, D.C. 20201or by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). OCR Complaint forms are available at
www.hhs.gov/ocr/office/file/index.html.
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