Horizon Blue Cross Blue Shield of New Jersey

OMNIA Bronze

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: 3000 Family: 6000 Per Person: 3000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: 8700 Family: 17400 Per Person: 8700
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $50 Copay after deductible
Specialist	Standard: $75 Copay after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $25 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $500 Copay per day after deductible
Inpatient Services	Standard: $0 Copay after deductible

Emergency and Urgent Care

Emergency Room

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

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