Horizon Blue Cross Blue Shield of New Jersey - OMNIA Silver
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$15 Copay
100% Coinsurance
Specialist Visit
$35 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$35 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
$20 Copay after deductible
100% Coinsurance
X-rays and Diagnostic Imaging
$20 Copay after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
$20 Copay after deductible
100% Coinsurance
Generic Drugs
$10 Copay
100% Coinsurance
Preferred Brand Drugs
10% Coinsurance after deductible
100% Coinsurance
Non-Preferred Brand Drugs
30% Coinsurance after deductible
100% Coinsurance
Specialty drugs
30% Coinsurance after deductible
100% Coinsurance
Outpatient Facility Fee
$250 Copay after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
$0 Copay after deductible
100% Coinsurance
Emergency Room Services
$100 Copay with deductible
100% Coinsurance
Emergency Transportation/Ambulance
No Charge after deductible
100% Coinsurance
Urgent Care
$70 Copay
100% Coinsurance
Inpatient Hospital Services
$250 Copay per day after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
No Charge after deductible
100% Coinsurance
Mental/Behavioral Health Outpatient Services
$15 Copay after deductible
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$250 Copay per day after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$15 Copay after deductible
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$250 Copay per day after deductible
100% Coinsurance
Prenatal and postnatal care
$35 Copay
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$250 Copay after deductible
100% Coinsurance
Home Healthcare Services
$5 Copay
100% Coinsurance
Outpatient Rehabilitation Services
$20 Copay after deductible
100% Coinsurance
Habilitation Services
$20 Copay after deductible
100% Coinsurance
Skilled Nursing Facility
$250 Copay per day after deductible
100% Coinsurance
Durable Medical Equipment
No Charge
100% Coinsurance
Hospice Services
$20 Copay after deductible
100% Coinsurance
Chiropractic Care
$15 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$20 Copay after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
$20 Copay after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$35 Copay
100% Coinsurance
Diabetes Education
$35 Copay
100% Coinsurance
Nutritional Counseling
$35 Copay
100% Coinsurance
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
No Charge after deductible
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
Not covered
Not covered
Dental Check Up (Child)
Not covered
Not covered
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
Not covered
Not covered
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
Not covered
Not covered
Routine Dental Services (Adult)
Not covered
Not covered