![]() and Horizon Blue Cross Blue Shield of New Jersey are independent licensees of the Blue Cross and Blue Shield Association serving residents of New Jersey. and Horizon Blue Cross Blue Shield of New Jersey. eHealthInsurance is an independent agency authorized to sell health plans in New Jersey through Horizon Healthcare of New Jersey, Inc.Click here to view the Uniform Glossary of Coverage and Medical Terms.Ĭarrier specific notices, disclaimers and fees A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. The Summary of Benefits & Coverage can be found at.Insurance companies reserve the right to change the terms of a policy upon proper notification. The insurance company always determines your actual premium. 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 quotes or rates shown above are estimates only. Please check below for information regarding the plans and carriers you selected. These amounts are subject to change.Įach insurance carrier may have unique Notices, Disclaimers, and Fees. The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network. Only the terms and conditions of coverage benefits listed in the policy are binding. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. The information shown here is a summary of benefits for informational purposes only. The carrier has not provided a separate document for Exclusions and Limitations. Out-of-Network Annual Out-of-Pocket LimitĮlectronic Signature for Application Available $10 Copay, limited to 30 Visit(s) per Year No Charge, limited to 1 Visit(s) per Year $500 Copay after deductible per day, A copay is required for up to 5 days $500 Copay per Day after deductible, A copay is required for up to 5 days Inpatient Hospital Services: $500 Copay per Day after deductible, A copay is required for up to 5 days Inpatient Physician and Surgical Services: $0 Copay after deductible $20 Copay after deductible, limited to 30 Visit(s) per Year Outpatient Rehabilitation Services (PT, OT, ST) ![]() ![]() Outpatient Lab: $20 Copay X-rays: $20 Copay Outpatient Surgery Physician/Surgical Services: $0 Copay after deductible Outpatient Facility Fee: $250 Copay after deductible Generic Drugs: $20 Copay Preferred Brand Drugs: $50 Copay Non-Preferred Brand Drugs: $75 Copay Specialty Drugs: $75 Copay Office Visit for Other Practitioner (Nurse, Physician Assistant) Office Visit for Primary Doctor Find Doctors
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