The Direct Access Plan 375 provides you with the flexibility to receive care from both in-network providers and out-of-network providers
In New Jersey, members have access to all doctors, specialists and hospitals that participate in Horizon’s Managed Care Network (“Direct Access”). Outside of New Jersey throughout the United States and worldwide, members have access to doctors and hospitals through the BlueCard® PPO program. Alternatively, members may seek treatment through any licensed provider outside of the Managed Care Network.
In-network preventive care services as defined by the plan are covered at 100%, meaning there is no copay for these types of services and these services are not subject to the deductible. All other in-network services are covered at 100% after meeting the in-network deductible of $375 for an individual or $750 for those members in a two-person or family contract. Once the deductible is met the applicable copay for the service and/or facility will apply. Copays are $20 for primary care office visit, $40 for specialist office visit and $100 for emergency room visit. Laboratory services must be performed at the in-network lab facility, LabCorp or Quest. Prescription copays are $10 for preferred generic drugs, $25 for preferred name brand drugs and $50 for non-preferred drugs. There is a mail-order option through Prime Therapeutics which can result in cost savings.
For out-of-network services, you are responsible for paying the full cost of care until you reach the out-of-network deductible. You are then responsible for a portion of the cost of care (your coinsurance of 30%) until you reach the out-of-pocket maximum. Refer to the Summary of Benefits and Coverage for additional information.