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Medical Benefits

Horizon BCBSNJ:  Omnia Platinum Plan Highlights

What is the overall deductible?

·        0$ for OMNIA Tier 1 providers.

·        $1,000 Individual or $2,000 Family for Tier 2 providers

What is the out-of-pocket limit for this plan?

·        For Health/Pharmacy OMNIA Tier 1 providers $1,900 Individual/ $3,800 Family

·        For Health/Pharmacy OMNIA Tier 2 providers $3,000 Individual/$6,000 Family

Do you need a referral to see a specialist?

·        NO


Common Medical Events – Tier One Providers

Primary care visit to treat an injury or an illness: $10.00 Copayment per visit

Specialist visit: $15.00 Copayment per visit

Preventive care/screening/immunization: NO CHARGE

Diagnostic test (x-ray, blood work): NO CHARGE for Office, Independent, Laboratory, Outpatient Hospital

Imaging (CT/PET scans, MRIs): $15.00 Copayment per visit for Outpatient Facility


If you need drugs to treat your illness or condition – Tier 1 Provider

Generic Drugs: $5.00 Copayment/Retail

Preferred Brand Drugs: $15.00 Copayment/Retail

Non-preferred brand drugs: $30.00 Copayment/Retail

Specialty drugs: $30.00 Copayment/Retail


If you have outpatient surgery – Tier 1 Provider

Facility fee (e.g., ambulatory surgery center): $150.00 Copayment per visit for Ambulatory Surgical Center, Outpatient Hospital

Physician/surgeon fees: No charge for Ambulatory Surgical Center, Outpatient Hospital


If you need medical attention – Tier 1 Provider

Emergency room care: $100 Copayment per visit for Outpatient Hospital

Emergency medical transportation: NO CHARGE

Urgent Care: $30.00 Copayment


If you have a hospital stay – Tier 1 Provider

Facility Fee (e.g., hospital room): $300.00 Copayment per day for Inpatient Hospital


If you need mental health, behavioral health, or substance abuse services – Tier 1 Provider

Outpatient Services: NO CHARGE for Outpatient Hospital

Inpatient Services: $300 Copayment per day for Inpatient Hospital

(Subject to change at plan renewal time WITHOUT notice)