Horizon Blue Cross Blue Shield of New Jersey

Horizon Advantage EPO Silver

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $2,500 Family: $5,000 Per Person: $2,500
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Medical Out-of-Pocket Maximum	Individual: $8,100 Family: $16,200 Per Person: $8,100
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $30 Copay
Specialist	Standard: $50 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: 50% Coinsurance
Non Preferred Brand Drugs	Standard: 50% Coinsurance
Generic Drugs	Standard: $15 Copay
Specialty Drugs	Standard: 50% Coinsurance

Inpatient Coverage

Hospital Services	Standard: 50% Coinsurance after deductible
Inpatient Services	Standard: 50% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $100 Copay with deductible<br>50% Coinsurance after deductible

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