Horizon Blue Cross Blue Shield of New Jersey - OMNIA Silver HSA
Primary Care Visit
$15 Copay after deductible
100% Coinsurance
Specialist Visit
$30 Copay after deductible
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$30 Copay after deductible
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
$25 Copay after deductible
100% Coinsurance
X-rays and Diagnostic Imaging
$25 Copay after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
30% Coinsurance after deductible
100% Coinsurance
Generic Drugs
50% Coinsurance after deductible
100% Coinsurance
Preferred Brand Drugs
50% Coinsurance after deductible
100% Coinsurance
Non-Preferred Brand Drugs
50% Coinsurance after deductible
100% Coinsurance
Specialty drugs
50% Coinsurance after deductible
100% Coinsurance
Outpatient Facility Fee
30% Coinsurance after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
30% Coinsurance after deductible
100% Coinsurance
Emergency Room Services
$100 Copay
30% Coinsurance after deductible
30% Coinsurance after deductible
100% Coinsurance
Emergency Transportation/Ambulance
30% Coinsurance after deductible
100% Coinsurance
Urgent Care
$60 Copay after deductible
100% Coinsurance
Inpatient Hospital Services
30% Coinsurance after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
30% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Outpatient Services
30% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Inpatient Services
30% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
30% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Inpatient Services
30% Coinsurance after deductible
100% Coinsurance
Prenatal and postnatal care
$30 Copay after deductible
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
30% Coinsurance after deductible
100% Coinsurance
Home Healthcare Services
$5 Copay after deductible
100% Coinsurance
Outpatient Rehabilitation Services
30% Coinsurance after deductible
100% Coinsurance
Habilitation Services
30% Coinsurance after deductible
100% Coinsurance
Skilled Nursing Facility
30% Coinsurance after deductible
100% Coinsurance
Durable Medical Equipment
No Charge after deductible
100% Coinsurance
Hospice Services
30% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
$15 Copay after deductible
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
30% Coinsurance after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
30% Coinsurance after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$30 Copay after deductible
100% Coinsurance
Diabetes Education
$30 Copay after deductible
100% Coinsurance
Nutritional Counseling
$30 Copay after deductible
100% Coinsurance
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
30% Coinsurance 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