Horizon Blue Cross Blue Shield of New Jersey
2014 Managed Care Benefits-at-a-Glance*
If you have questions about enrollment, benefits or claims, visit NaviNet.net or call 1-800-624-1110 to use our
Interactive Voice Response system, available 24 hours a day, seven days a week, generally including weekends
and holidays.
Preventive and Well Care
As a result of health care reform, there is no cost sharing for preventive services. Some services such as adult physicals, well child care and immunizations
are covered at 100 percent, without any copayment, coinsurance or deductible. Some plans require services to be provided by the member’s Primary Care
Physician (PCP) or by a participating health care professional when referred by the PCP, as appropriate. Please go online or call to verify benefits.
Products and Alpha Prefixes
Horizon Advance EPO
JGW, JGX
Are Referrals
Required?
For adults, services must be provided by the member’s PCP or by a physician
or other health care professional that participates in Horizon Advance EPO
when referred by the PCP. Members are covered for medically necessary
exams for the diagnosis and treatment of eye diseases/conditions provided
by a physician. Adult vision hardware is not a covered benefit.
Pediatric vision care: Services must be provided by a participating Davis
Vision provider.
Child dependents (up to age 19) are eligible for the following:
• Eye exam. Limited to one exam per 12 month period.
• Lenses are covered once every 12 months.
• Vision hardware is reimbursed once every 24 months. Fashion level only.
Services must be provided by a physician or other health
care professional that participates in Horizon Advance
EPO. Referrals are required. Therapeutic manipulation
of the spine is covered and limited to 30 visits per
calendar year.
No
Coverage varies depending on the member’s contract.
Services must be provided by a participating physician or other health care
professional.
A copayment may apply for routine vision care. Members are covered for
medically necessary exams for the diagnosis and treatment of eye
diseases/conditions.
Vision coverage varies depending on the member’s policy.
Services must be provided by a participating health care professional.
Therapeutic manipulation of the spine is covered.
Benefits are limited. Coverage is limited to 30 visits per
calendar year and varies depending on the member’s
contract. Services must be provided by a participating
chiropractor. Copayment depends on policy specifics.
No
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
For in-network benefits: Services must be provided by a participating physician
or other health care professional.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
Vision coverage varies depending on the member’s policy.
For in-network benefits: Services must be provided by a participating health
care professional.
Therapeutic manipulation of the spine is covered.
Visit limits may apply. Coverage is limited to 30 visits per
calendar year and varies depending on the member’s
contract.
For in-network benefits: Services must be provided by
a participating chiropractor.
Yes
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
Vision coverage varies depending on the member’s policy.
Vision hardware is not a covered benefit.
Members may go to a participating chiropractor for
therapeutic manipulation of the spine without a referral.
Coverage is limited to 30 visits per calendar year.
No
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
Vision coverage varies depending on the member’s policy.
Vision hardware is not a covered benefit.
Members must go to a participating chiropractor for
therapeutic manipulation of the spine without a referral.
Coverage is limited to 30 visits per calendar year.
No
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
Vision coverage varies depending on the member’s policy.
Members must go to a participating chiropractor for
therapeutic manipulation of the spine without a referral.
Coverage is limited to 30 visits per calendar year.
Covered at 100% after deductible and office copayment.
Copayment depends on policy specifics.
Out-of-network benefits available; may be subject to
coinsurance and deductible. PCP selection is optional.
Horizon HMO
SNJ, YHM, YHO
No out-of-network benefits, except in an emergency.
Members must select a PCP.
Horizon HMO Access
YHM, YHO
No out-of-network benefits, except in an emergency.
PCP selection is optional.
Horizon HMO Access HSA
YHH, JGN
No out-of-network benefits, except in an emergency.
PCP selection is optional. Member must satisfy
deductible before copayments apply.
* Benefits current at time of printing.
Chiropractic Care
Services must be provided by the member’s PCP or by a physician or other health
care professional that participates in Horizon Advance EPO when referred by the
PCP. Referrals are required (if the Ob/Gyn is not the patient’s selected PCP).
The Gold level Horizon Advance EPO plan includes a copayment for
nonpreventive specialist services provided in an office setting.
The Silver level of Horizon Advance EPO applies coinsurance after a deductible
is met for nonpreventive specialist services provided in an office setting.
No out-of-network benefits, except in an emergency.
Horizon Direct Access
NJ DIRECT
NJX, YHQ, YHX
Vision Services
(Benefits for vision and vision hardware vary.)
Yes
PCP selection is required. All care must be coordinated
by the PCP. Members must use physicians and other
health care professionals that participate in Horizon
Advance EPO. No out-of network benefits, except in
an emergency.
Members using in-network Preferred Tier 1 hospitals will
have lower cost sharing than those who receive services
at in-network Tier 2 hospitals.
Horizon Advantage EPO
JGV, JGY, JGZ, YKH, YKQ, YKL
Ob/Gyn Care
To view a list of services and supplies that require prior
authorization, visit HorizonBlue.com/Providers and:
• Click Provider Reference Materials.
• Click Utilization Management.
• Mouse over Utilization Management and click
Prior Authorization Lists.
• Click the product or group to review the appropriate prior
authorization list.
To obtain authorization, call 1-800-664-BLUE (2583).
(continues)
Horizon Blue Cross Blue Shield of New Jersey
2014 Managed Care Benefits-at-a-Glance*
If you have questions about enrollment, benefits or claims, visit NaviNet.net or call Physician Services at 1-800-624-1110.
Products and Alpha Prefixes
Horizon HMO Coinsurance Plus
YHM, YHO
Are Referrals
Required?
Ob/Gyn Care
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
Vision coverage varies depending on the member’s policy.
Vision hardware is not a covered benefit.
Members must go to a participating chiropractor for
therapeutic manipulation of the spine with a referral.
Coverage is for a maximum of 30 visits per calendar year.
Covered at 100% after office copayment.
Copayment depends on policy specifics.
No
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions. There is a copayment for annual
routine vision care.
$100 reimbursement for vision hardware (not associated with cataract surgery)
every two years. There is no copayment for annual glaucoma screening.
Members may go to a participating chiropractor for
manual manipulation of the spine to correct subluxation.
Routine chiropractic care is not covered.
$20 copayment applies for the individual product. Group
benefits may vary based on employer selection.
No copayment for group product.
Yes
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
There is a copayment for an annual routine eye exam, but referral receipts
are not required.
All other vision care requires a referral.
$100 reimbursement for vision hardware (not associated with cataract surgery)
every two years. There is no copayment for annual glaucoma screening.
Members may go to a participating chiropractor for
manual manipulation of the spine to correct subluxation.
Routine chiropractic care is not covered.
A $20 copayment applies.
Yes
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as the diagnosis is on our open access list.
Family Planning and Services: No copayment.
Infertility services are not covered.
Members are covered at 100% for routine eye exams.
Nonroutine eye exams are covered as any other illness.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
Members must use a participating Davis Vision provider for routine exam and
vision hardware.
No copayment applies.
Members may go to a participating chiropractor for
manual manipulation of the spine to correct subluxation.
No copayment applies.
No
For in-network benefits: Services must be provided by a participating physician
or health care professional.
A copayment may apply for routine vision care.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
For in-network benefits: Services must be provided by a participating health
care professional.
Therapeutic manipulation of the spine is covered.
Visit limits may apply. Coverage and limits vary
depending on the member’s contract.
Copayment depends on policy specifics.
For in-network benefits: Services must be provided by
a participating chiropractor.
Yes, for the in-network
level of benefits
Members may go directly to a participating Ob/Gyn for routine and/or related
care without a referral as long as diagnosis is on our open access list.
For in-network benefits: Services must be provided by a participating physician
or health care professional.
Members are covered for medically necessary exams for the diagnosis and
treatment of eye diseases/conditions.
Vision coverage varies depending on the member’s policy.
For in-network benefits: Services must be provided by a participating health
care professional.
YHG members are only eligible through age 17 years for a vision screening
by a pediatrician.
In-network services require a referral. Coverage and
limits vary depending on the member’s contract.
Copayment depends on policy specifics.
For in-network benefits: Services must be provided by a
participating chiropractor.
Out-of-network benefits available, subject to higher
member out-of-pocket costs.
No prior authorizations required for out-of-network benefits.
Horizon Medicare Blue Value (HMO)
Horizon Medicare Blue Choice (HMO)
YHV, YKO
No out-of-network benefits, except in an emergency.
Horizon Medicare Blue TotalCare (HMO SNP)
YHV, YKI
No out-of-network benefits, except in an emergency.
All care must be coordinated by the PCP.
Horizon MyWay (Horizon Direct Access Plan Design)
NJ DIRECT HD1500 and NJ DIRECT HD4000
JGB, JGE, JGH, NJX
Out-of-network benefits available; may be subject to
coinsurance and deductible. PCP selection is optional.
Horizon POS
HSE, YHD, YHG, YHP
Out-of-network benefits available; may be subject to
coinsurance and deductible.
Members must select a PCP.
Patient-Centered Advantage EPO
JGR
This plan uses tiered copayment levels to encourage
enrolled members to select and use a participating
Managed Care Network PCP who is affiliated with a
practice in one of our patient-centered programs:
Patient-Centered Medical Home (PCMH) or Accountable
Care Organization (ACO).
Chiropractic Care
Yes
No out-of-network benefits, except in an emergency.
Some members’ benefits may be subject to
coinsurance.
Please check the member’s ID card for details.
Horizon Medicare Blue (PPO)
YKM (Individual), YKK (Group)
Vision Services
(Benefits for vision and vision hardware vary.)
No
There is no cost sharing for preventive services.
Ob/Gyn care is covered at 100% after applicable office visit copayment.
.
A copayment may apply for routine vision care. Members are covered for
medically necessary exams for the diagnosis and treatment of eye
diseases/conditions.
Vision coverage varies depending on the member’s policy.
Services must be provided by a participating health care professional.
Therapeutic manipulation of the spine is covered.
Benefits are limited.
Coverage is limited to 30 visits per calendar year.
Services must be provided by a participating
chiropractor.
Copayment depends on policy specifics.
* Benefits current at time of printing. The prefix information listed in this document is confidential. Participating Horizon Blue Cross Blue Shield of New Jersey physicians and other health care professionals and their office staff agree to use such information only for purposes of identifying health insurance claims/service contact information for Horizon BCBSNJ and/or other Blue Cross and/or Blue Shield Plan patients and not for
other purposes and will not divulge any such information to any other party. Any reproduction of this information, in whole or in part, is prohibited without the permission of Horizon BCBSNJ. Products and services provided by Horizon BCBSNJ, an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield
Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.
© 2014 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.
27023B (W0714)