Horizon Blue Cross Blue Shield of New Jersey

OMNIA Silver

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $1,550 Family: $3,100 Per Person: $1,550
Prescription Drug Deductible	Individual: $250 Family: $500 Per Person: $250
Medical Out-of-Pocket Maximum	Individual: $8,000 Family: $16,000 Per Person: $8,000
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 after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $15 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $500 Copay per day after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: $100 Copay with deductible

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