The Traditional Direct Access Plan provides subscribers and their enrolled dependents 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. Refer to the Summary of Benefits for a description of preventive and well care services. All other in-network services are covered at 100% with the applicable copay for the service and/or facility Copays are $20 for primary care office visit, $40 for specialist office visit, and $100 for an emergency room visit. Short term therapies such as physical or speech therapy, respiratory therapy as well as chiropractic services require a $20 copay. Laboratory services must be processed at the in-network lab facility, Quest. Prescription copays at the retail pharmacy are $10 for preferred generic drugs, $25 for preferred name brand drugs, and $50 for non-preferred drugs for a 30 day supply. 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. Out-of-network deductible is $500 per person and $1,000 per family. 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 Plan Design for additional information.