Horizon Blue Cross Blue Shield of New Jersey

OMNIA Gold

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $950 Family: $1,900 Per Person: $950
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $4,500 Family: $9,000 Per Person: $4,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $10 Copay
Specialist	Standard: $25 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $50 Copay
Non Preferred Brand Drugs	Standard: $75 Copay
Generic Drugs	Standard: $20 Copay
Specialty Drugs	Standard: $75 Copay

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

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