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Plan Decision Guide

Individual and Family Health Coverage from Horizon Blue Cross Blue Shield of New Jersey

• Horizon Basic and Essential EPO and EPO Plus • Horizon HMO• Horizon Direct AccessAlso Inside: Plan Premiums and Enrollment Form

HORBR204

Pre-existing Condition Limitation Only Applies to Individuals Age 19 and Older.

Definition of a “pre-existing” condition:A “pre-existing condition” is an illness or injury that manifests itself in the six months before the enrollment date and for which:

•apersonseesadoctor,takesprescribeddrugsor receivesothermedicalcareortreatment,orhad medicaltreatmentrecommendedbyadoctor,or

•anordinarilyprudentorcarefulpersonwouldhavesoughtmedicaladvice,careortreatment.

A pregnancy that exists on the effective date of your coverageisalsoapre-existingcondition.However, complicationsofpregnancy,asdefinedinN.J.A.C. 11:1-4.3,arenotconsideredpre-existingconditionsandare not subject to the pre-existing condition limitation.

How does this limitation affect coverage?Ifthislimitationapplies,nobenefitswillbepaidforcharges incurred for the covered person’s pre-existing condition until 12 months after the enrollment date.

Exceptions to the limitation:The pre-existing condition limitation does not apply to anyindividualunderage19andtogeneticinformation, in the absence of a diagnosis of the condition related to that information.

This limitation may not apply if you transfer from another health insurance plan and there has been no more than a 31-day lapse in coverage. The limitation also does not apply to Federally Defined Eligible Individuals who apply for coverage within 63 days of termination of prior coverage. Additional limitations and exclusions may apply.

12 HorizonBlueCrossBlueShieldofNewJersey

Pre-existing Conditions Limitation

A variety of plan choices for individuals and familiesHorizon Blue Cross Blue Shield of NewJerseyispleasedtoofferafull range of health plan choices for individuals and families. Whether you are purchasing an individual health insuranceplanforthefirsttime,orsimplylookingtogetmoreforyour premiumdollar,we’reconfidentyou’llfind a plan that fits your exact needs and budget.

Accesstobroadprovidernetwork Withourplanchoices,youhaveaccesstothelargeHorizonManagedCareNetwork.Ouragreements with these participating doctors and specialists allow you to save on the premiums and the cost of covered services. Dozens of leading institutions recognize HorizonBlueCrossBlueShieldofNewJerseyand acceptourcoveragewithnopaperworkrequired. It’slikelythatthedoctorsandhospitalsyoucurrently useparticipateinournetwork.

Available prescription drug coverage with selected plans The high costs for outpatient prescription drugs are a concernformanyNewJerseyresidents.That’swhymostof our plan options include coverage to help cover the costs of commonly prescribed medications.

Guaranteed renewabilityOncecoveragegoesintoeffect,itis

guaranteed renewable. This means that as long as your premiums are paid on time,yourcoveragewillreneweachyear without proof of good health. Some limitations apply.

Coverage away from home Forallplans,medicalemegenciesare

covered while traveling outside of the HorizonManagedCareNetworkatthe

in-networkbenefitlevel.OurHMO,EPOandEPO Plus plans do not cover non-emergency out-of-networkservices,unlessotherwiseauthorized.The Individual Direct Access plans do cover eligible non-emergency medical services while outside of the HorizonManagedCareNetworkattheout-of-networklevel.Tomaximizeeligibleout-of-networkbenefits,Horizon Direct Access members have the option of using ourBlueCardTraditionalNetworkwhiletravelingoutsideoftheHorizonManagedCareNetwork.TheseBlueCardTraditional Providers will accept the negotiated rates and will not balance bill the member for the difference. Tofindaparticipatingphyscian,justcallthetoll-freenumberonthebackofyourIDcard.

Plan Decision Guide 1

Individual and Family Health Coverage from the State’s Leading Health Insurer: HorizonBlueCrossBlueShieldofNewJersey

Putourcoverageadvantagestoworkforyouwithaplanthatmeetsyourneeds and fits your budget!Forover75years,we’vebeenhelpingNewJerseyresidentswiththeirhealthcare coverageneeds.Today,nearly3.6millionmembershavecometousforreliable coverage andthesecurityoftheBlueCrossandBlueShieldname.Ourstrength,experienceand dependable planshavehelpedmakeusthelargesthealthinsurerinNewJersey. Here are just a few advantages you’ll find when you choose individual health coverage fromHorizonBlueCrossBlueShieldofNewJersey.

EligibilityUnderNewJerseylaw,youmaynotbe denied health insurance coverage becauseofamedicalcondition,age,sex,occupation or where you live in the state. However,youmustbeaNewJerseyresident.

You or any dependents you wish to enroll must not be covered or eligible under:

•Another individual health benefits plan

•A group health benefits plan that provides the same or similar coverage (as that phrase has been interpreted through regulation)

•Medicare

Eligibledependentsincludeyourspouse,domesticpartnerorcivilunionpartner,andyourchildren(includingthosein your legal custody and guardianship) who are under age 26. Special rules apply to the continuation of coverage beyond age 26 for handicapped children.

How to applySimply complete the enclosed enrollment form. To savetimeinprocessing,besuretoanswerallquestionscarefully and completely for yourself and all eligible dependents. Be sure to indicate your choice of plan and deductibleorcopayment,ifapplicable.

Payment options You may pay your initial premium by credit card. Monthly premiumsmaybepaidbyautomaticmonthlybankdraftor direct bill each month. If paying by direct bill, please enclose a check or money order for your first month’s premium.Ifchoosingautomaticmonthlybankdraft,pleaseattachavoidedchecktoyourenrollmentform.

Changing plans? If you have health insurance with

usoranothercompany,youneedto knowthefollowinginformationwhen

changing plans:

From group coverage… Ifyouareeligibleforgroupcoverage,youcanonly enroll in individual coverage that is not the same or similartoyourgroupcoverageduringtheNovemberopenenrollmentforaJanuary1effectivedate.Yourgroup coverage termination must coincide with the effective date of your new policy with us.

From individual coverage... If you already have coverage under an individual plan offeredbyHorizonBlueCrossBlueShieldofNewJersey oranothercarrier,restrictionsmayapplytochanging coverage.Pleasecallyouragent,brokeroraHorizonBCBSNJSalesRepresentativeat1-888-425-5611for more information.

Questions About Applying or Changing Plans? NeedMoreInformation?

Feel free to call your agent or broker – or call us toll-free at 1-888-425-5611, Monday through Friday, from 8:30 a.m. to 5:00 p.m. ET. Ifyouhaveahearingimpairment,callour telecommunication device at 1-800-852-7899.

You can also visit us online at www.HorizonBlue.com

2HorizonBlueCrossBlueShieldofNewJersey

Choose the Plan that WorksBestforYouAtHorizonBlueCrossBlueShieldofNewJersey,wewanttomakeitaseasy as possible to choose the individual or family health care plan that worksforyouandmeetsyourbudget.Usethechartbelowtoidentifykeyfeatures of each plan.

•Cost-savingfeaturesdesignedtokeeppremiumslow

•HealthcareservicesthroughtheHorizonManagedCareNetwork

•NoPrimaryCarePhysicianrequiredandno referrals needed

•$30officevisitcopaymentavailablewithEPO Plus coverage

An ideal option for people on a limited budget – like recent college grads or the unemployed.

Name:

ID:Group No.

Effective Date:BC Plan Code:

BS Plan Code:

Sample A. Sample123-45-6789AB123401/01/2006

121621

2011


BeforeSigningUpforaPlan, You Should Know…

•Nocostsharingforpreventivecare•Achoiceofcopaymentoptionsstartingaslowas$15•Lowout-of-pocketcostswithhealthcareservicesreceivedthroughaPrimaryCarePhysician(PCP)

•ExtensiveHMOnetworkofphysiciansandhospitalsplus out-of-state medical emergency coverage

A combination of cost-saving features and comprehensive coverage makes this a popular choice for many New Jersey residents, especially those with families.

Horizon Basic and Essential EPO and EPO Plus plans Forexceptionalaffordability,essentialcoverage,noprimary carephysicianrequirementandnoreferrals

Horizon HMO plans Forcomprehensivecoverage,lowout-of-pocketcostsandanextensivenetworkofphysiciansandhospitals,chooseaHorizonHMOplanPlan features:

Plan features:

•Comprehensivecoveragethatincludes preventive care

•ReceivehealthcareservicesthroughtheHorizonManagedCareNetworkorgoout-of-network

•PrimaryCarePhysician(PCP)selection recommendedformaximumbenefit,butnotrequiredandnoreferralneeded

A comprehensive health plan offering coverage for a wide range of services plus maximum freedom of choice.

Horizon Direct Access plans Forcomprehensivecoverage,accesstoin-andout-of-network providers and no referralsPlan features:

*This is only a summary of benefits; a complete list of exclusions will be provided in your Evidence of Coverage.

Horizon Basic and Essential EPO and EPO Plus Benefits-at-a-GlanceThechartbelowisonlyforillustrativepurposes.Onceyouareenrolled,acompletelistofdetailsandexclusionswillbeprovided in your individual contract/policy.

Plan Decision Guide 54HorizonBlueCrossBlueShieldofNewJersey

Description of service Horizon Basic and essential epo Horizon Basic and essential epo plus

Physician/Specialist Services Consultation,medicaland surgicalservices,assistant surgeon,anesthesiaand maternity care

Outpatient/Out-of-hospital/Illness and injury officevisitscoveredto$700percovered person per calendar year.

Wellnessvisitscoveredto$600percovered person per calendar year.

Outpatient/Out-of-hospital/Office visits — $30copaymentpercoveredpersonpervisit.

Wellnessvisitscoveredto$600percovered person per calendar year.

Physical Therapy Outpatient (30 visits per covered person per calendar year)

$20copaymentpercoveredpersonpervisit.

Maternity Services Physician Services

Delivery charge covered; pre- and post-natal charges are covered when included in the delivery charge.

$30copaymentforinitialvisit;inpatientstaysubject to inpatient hospital charges.

Inpatient Hospital Services (90 days per covered person per calendar year)

$500copaymentpercoveredpersonperperiodofconfinement.

Outpatient Hospital Services Outpatient Surgery and Ambulatory Surgery

$250copaymentpercoveredpersonpersurgery.

Out-of-Hospital Diagnostic Tests

$500maximum per covered person per calendar year.**

Emergency Room Copayment $100copaymentpercoveredpersonpervisit(waivedifadmitted).

Alcohol and Substance Abuse Inpatient (30 days per covered person per calendar year)

30%coinsuranceafter$500hospitalconfinementdeductible.

Alcohol and Substance Abuse Outpatient (30 visits per covered person per calendar year)

30%coinsurance.

Mental Illness (BBMI) Inpatient (90 days per covered person per calendar year)

$500copaymentpercoveredpersonperperiodofconfinement.

Mental Illness (BBMI) Outpatient (30 visits per covered person per calendar year)

30%coinsurance.

Description of service Horizon Basic and essential epo Horizon Basic and essential epo plus

Prescription Drugs (Obtainedwhilenotconfined in a hospital)

Notcovered. $15copaymentforgenericdrugswithonecopaymentper30-daysupplyforretailand mailorder;50%coinsuranceforbrandname drugsupto$500maximumpercovered person per calendar year.

Home Health Care Notcovered. 50%coinsuranceupto$2,500maximumpercovered person per calendar year.

Durable Medical Equipment Notcovered. 50%coinsuranceupto$2,500maximumpercovered person per calendar year.

Hospice Care Notcovered. 50%coinsuranceupto$2,500maximumpercovered person per calendar year.

Diabetes Benefits Notcovered. 50%coinsuranceupto$2,500maximumpercovered person per calendar year.

Birthing Center Confinement Birthing Center charges not covered. $250copaymentpercoveredpersonper period of confinement.

Rehabilitation Center Confinement RehabilitationCenterchargesnotcovered. $500copaymentpercoveredpersonperperiodof confinement; the copayment does not apply if admission is preceded by a hospital confinement; maximum90dayspercalenderyear.

Casts, Braces, Trusses, Prosthetic Devices, Orthopedic Footwear and Crutches

Notcovered. Casts,prostheticdevicesandcrutchesare covered.

Chemotherapy, Infusion Therapy Notcovered. Covered.

Transplants Notcovered. Covered.

exclusions* Horizon Basic and essential epo Horizon Basic and essential epo plus

Ambulance, Routine Foot Care, Skilled Nursing Facility Care, Therapeutic Manipulation (Chiropractic), Treatment of a Non-Biologically Based Mental Illness

Notcovered.

Inpatient practitioner’s fees connected with inpatient hospital confinement are covered under inpatient hospital services.

**Fordiagnosticservicesrenderedintheoffice,freestandingoranoutpatientfacility.

Horizon HMO Benefits-at-a-GlanceThechartbelowisonlyforillustrativepurposes.Onceyouareenrolled,acompletelistofdetailsandexclusionswillbeprovided in your individual contract/policy.


Description of service Horizon HMo $15 Horizon HMo $30 Horizon HMo $30/$50

Primary Care Physician Copayment $15pervisit. $30pervisit. $30pervisit.

Specialist Copayment $15pervisit. $30pervisit. $50pervisit.

Annual Deductible N/A N/A N/A

Coinsurance 50%forprescriptiondrugs. 50%forprescriptiondrugs. 50%forprescriptiondrugs.

Maximum Out-of-Pocket N/A N/A N/A

Lifetime Benefit Maximum Unlimited Unlimited Unlimited

Inpatient Hospital (includingbiologicallybased mental illness and alcoholism) (subjecttopreapproval)

$150copaymentperdayfora maximum of 5 days per admission;$1,500maximum per calendar year.

$300copaymentperdayforamaximumof5daysper admission;$3,000maximumpercalendaryear.

Ambulatory Surgical Center Facility Charges

$15pervisit. $30pervisit. $30pervisit.

Hospital Outpatient Surgery Facility Charges

$15pervisit. $30pervisit. $60pervisit.

Emergency Room Copayment $100copayment(waivedifadmittedwithin24hours).

Non-Biologically Based Mental Illness and Substance Abuse

Inpatient(subjecttopreapproval):100%afterthehospitalcopaymentfora maximumof30daysperyear(1inpatientdaymaybeexchangedfor2outpatientvisits).

Outpatient:100%aftertheofficevisitcopaymentforamaximum20visitspercalendaryear.

Blood/Blood Products/ProcessingPlanpays100%. Planpays100%. Planpays100%.

Diagnostic X-ray $15copaymentpervisit. $30copaymentpervisit.

LabPlanpays100%whenprovidedbyanetworklab.

Durable Medical Equipment (Subjecttopreapproval) Planpays100%. Planpays100%. Planpays100%.

Home Health Care and Hospice Care (Subjecttopreapproval) Unlimited days. Unlimited days. Unlimited days.

Maternity $25copaymentfortheinitialvisit;$0copaymentthereafter.

Prescription Drugs 50%coinsurance. 50%coinsurance. 50%coinsurance.

Preventive Care $0copaymentpervisit. $0copaymentpervisit. $0copaymentpervisit.

Rehabilitation Centers (Subjecttopreapproval)

Subject to inpatient hospital copayment above. Waived if immediately preceded by an inpatient stay.

Speech, Physical (subjectto preapproval), Occupational and Cognitive Rehabilitation Therapies

$15copaymentpervisit. $30copaymentpervisit.

Therapeutic Manipulations $15copaymentpervisit.Limited to30visitspercalendaryear

and 2 modalities per visit.

$30copaymentpervisit.Limited to30visitspercalendaryear

and 2 modalities per visit.

$30or$50copaymentpervisit.Limitedto30visitspercalendar year and 2 modalities per visit.

Description of service Horizon HMo $50/$70 Horizon HMo coinsurAnce

Primary Care Physician Copayment $50pervisit. $40pervisit.

Specialist Copayment $70pervisit. Subject to deductible and coinsurance.

Annual Deductible N/A $2,500Individual/$5,000Family Deductible(Aggregate).

Coinsurance 50%forprescriptiondrugs. 50%coinsurance.

Maximum Out-of-Pocket N/A $5,000Individual/$10,000Family.

Lifetime Benefit Maximum Unlimited

Inpatient Hospital (includingbiologicallybasedmentalillness andalcoholism)(subjecttopreapproval)

$500copaymentperdayforamaximumof 5daysperadmission;$5,000maximumper calendar year.

Subject to deductible and coinsurance.

Ambulatory Surgical Center Facility Charges $50pervisit. Subject to deductible and coinsurance.

Hospital Outpatient Surgery Facility Charges $100pervisit. Subject to deductible and coinsurance.

Emergency Room Copayment $100copayment(waivedifadmittedwithin 24 hours).

$100copayment(waivedifadmittedwithin24hours). Emergency room copayment is payable in addition to applicable deductible and coinsurance.

Non-Biologically Based Mental Illness and Substance Abuse

Inpatient(subjecttopreapproval):100% after the hospital copayment for a maximum of30daysperyear(1inpatientdaymaybeexchanged for 2 outpatient visits). Outpatient: 100%aftertheofficevisitcopaymentfora maximum20visitspercalendaryear.

Subject to deductible and coinsurance/Maximum of30daysinpatientcarepercalendaryear. One inpatient day may be exchanged for 2 outpatientvisits;maximum20visitsper calendar year.

Blood/Blood Products/Processing Planpays100%. Subject to deductible and coinsurance.

Diagnostic X-ray $50copaymentpervisit. Subject to deductible and coinsurance.

Lab Planpays100%whenprovidedbyanetworklab. Subject to deductible and coinsurance.

Durable Medical Equipment (Subjecttopreapproval)

Planpays100%. Subject to deductible and coinsurance.

Home Health Care and Hospice Care (Subjecttopreapproval)

Unlimited days. Unlimited days; subject to deductible and coinsurance.

Maternity $25copaymentfortheinitialvisit;$0copaymentthereafter.

Prescription Drugs 50%coinsurance. Subject to deductible and coinsurance. Coinsurance paid for covered prescription drugs does not count toward the maximum out-of-pocket.

Preventive Care $0copaymentpervisit. $0copaymentpervisit.


Subject to inpatient hospital copayment above. Waived if immediately preceded by a hospital inpatient stay.

Subject to deductible and coinsurance.

Speech, Physical (subjecttopreapproval),Occupational and Cognitive Rehabilitation Therapies

$30copaymentpervisit. Subject to deductible and coinsurance. Limitedto30visitspercalendaryear.

Therapeutic Manipulations $30copaymentpervisit.Limitedto30visits per calendar year and 2 modalities per visit.

Subject to deductible and coinsurance. Limited to 30visitspercalendaryearand2modalitiespervisit.

inDiviDuAl Direct Access plAn c 80/70inDiviDuAl Direct Access plAn c 100/70

Horizon Direct AccessBenefits-at-a-GlanceThechartbelowisonlyforillustrativepurposes.Onceyouareenrolled,acompletelistofdetailsandexclusionswillbe provided in your individual contract/policy.


Description of service in-network out-of-network Primary Care Physician Copayment* $30copaymentpervisittoselectedPCP.

$50copaymentpervisitifnoPCPisselected.Subjecttoout-of-networkdeductibleand30%coinsurance.

Specialist Copayment $50copaymentpervisit. Subjecttoout-of-networkdeductibleand30%coinsurance.

Annual Deductible N/A $7,500Individual/$15,000Family(Aggregate).

Coinsurance Applies to Prescription Drugs only. Planpays50%/Youpay50%.

Planpays70%/Youpay30% (50%forPrescriptionDrugs).

Maximum Out-of-Pocket (Doesnotinclude prescription drugs)

$5,000Individual/$10,000Family. $22,500Individual/$45,000Family.


Inpatient Hospital (Subjecttopreapproval) (includingbiologicallybasedmentalillness)

$300copaymentperdayforamaximumof5days peradmission;$3,000maximumpercalendaryear.

Subjecttoout-of-networkdeductibleand30%coinsurance.

Ambulatory Surgical Center Facility Charges $30copaymentpervisit. Subjecttoout-of-networkdeductibleand30%coinsurance.

Hospital Outpatient Surgery Facility Charges $60copaymentpervisit. Subjecttoout-of-networkdeductibleand30%coinsurance.

Emergency Room Copayment $100copaymentpervisit(waivedifadmitted within 24 hours).

$100copayment(waivedifadmittedwithin24hours) isinadditiontoout-of-networkdeductibleand 30%coinsurance.

Alcoholism(Subjecttopreapproval)

Inpatient:$300copaymentperdayformaximum of5daysperadmission;$3,000maximumper calendar year.


Non-Biologically Based Mental Illness and Substance Abuse •Inpatientconfinement:subjecttopreapproval, limitedto30dayspercalendaryear(1inpatient day may be exchanged for 2 outpatient visits)

•Outpatient:20visitspercalendaryear

Inpatient:100%aftertheinpatienthospitalcopayment. Outpatient:100%aftertheofficevisitcopayment.


Blood/Blood Products/Processing Planpays100%. Subjecttoout-of-networkdeductibleand30%coinsurance.

Diagnostic X-ray Determined by place of service. Subjecttoout-of-networkdeductibleand30%coinsurance.

Lab Planpays100%whenprovidedbyanetworklab. Subjecttoout-of-networkdeductibleand30%coinsurance.


Planpays100%. Subjecttoout-of-networkdeductibleand30%coinsurance.


Unlimited days. Subjecttoout-of-networkdeductibleand30%coinsurance.

Maternity $25copaymentfortheinitialofficevisitonly; Subject to inpatient hospital copayment.


Prescription Drugs (doesnotcounttowardmaximumout-of-pocket)

50%coinsurance. Notsubjecttodeductible.Coveredat50%coinsurance.

Preventive Care $0copaymentpervisit. Notsubjecttodeductibleandcoinsurance.Maximum of$500perindividual(exceptnewborns)percalendaryear.Newborns:Maximumof$750percalendaryear up to age 1.

Rehabilitation Centers (Subjecttopreapproval) Subject to inpatient hospital copayment. Waived if immediately preceded by an inpatient hospital stay.


Speech, Physical, Occupational and Cognitive Rehabilitation Therapies Limitedto30visitspercalendaryearpertherapy

$30copaymentpervisit. Subjecttoout-of-networkdeductibleand30%coinsurance.

Therapeutic Manipulations Limitedto30visitspercalendaryear and 2 modalities per visit


Description of service in-network out-of-networkPrimary Care Physician Copayment* $30copaymentpervisittoselectedPCP.

$50copaymentpervisitifnoPCPisselected.Subjecttoout-of-networkdeductibleand30%coinsurance.

Specialist Copayment $50copaymentpervisit. Subjecttoout-of-networkdeductibleand30%coinsurance.

Annual Deductible $2,500Individual/$5,000Family(Aggregate). $5,000Individual/$10,000Family(Aggregate).

Coinsurance Planpays80%/Youpay20%. (50%forPrescriptionDrugs).

Planpays70%/Youpay30%.




Inpatient Hospital (Subjecttopreapproval) (includingbiologicallybasedmentalillness)

Subjecttoin-networkdeductible and20%coinsurance.


Ambulatory Surgical Center Facility Charges Subjecttoin-networkdeductible and20%coinsurance.


Hospital Outpatient Surgery Facility Charges Subjecttoin-networkdeductible and20%coinsurance.


Emergency Room Copayment $100copayment(waivedifadmittedwithin24hours)isinadditiontoin-networkdeductibleand 20%coinsurance.

$100copayment(waivedifadmittedwithin24hours) isinadditiontoout-of-networkdeductibleand 30%coinsurance.

Alcoholism (Subjecttopreapproval) Inpatientandoutpatient:Subjecttoin-network deductibleand20%coinsurance.

Inpatientandoutpatient:Subjecttoout-of-networkdeductibleand30%coinsurance.

Non-Biologically Based Mental Illness and Substance Abuse •Inpatientconfinement:subjecttopreapproval, limitedto30dayspercalendaryear(1inpatient day may be exchanged for 2 outpatient visits)




Blood/Blood Products/Processing Subjecttoin-networkdeductible and20%coinsurance.


Diagnostic X-ray Determined by place of service. Subjecttoout-of-networkdeductibleand30%coinsurance.

Lab Planpays100%whenprovidedbyanetworklab. Subjecttoout-of-networkdeductibleand30%coinsurance.







Maternity $25copaymentforinitialofficevisitonly; Allotherservicessubjecttoin-network deductibleand20%coinsurance.



Notsubjecttodeductible.Coveredat50%coinsurance.

Preventive Care Notsubjecttodeductible,copayment and coinsurance.

Notsubjecttodeductibleandcoinsurance.Maximumof $500perindividual(exceptnewborns)percalendaryear.Newborns:Maximumof$750percalendaryearuptoage1.

Rehabilitation Centers(Subjecttopreapproval) Subjecttoin-networkdeductibleand20% coinsurance. Limitedto120dayscombined.






*PrimaryCarePhysician(PCP)selectionrecommendedformaximumbenefits,butnotrequiredandnoreferralneeded. *PrimaryCarePhysician(PCP)selectionrecommendedformaximumbenefits,butnotrequiredandnoreferralneeded.

inDiviDuAl Direct Access plAn A/50 70/50


Enjoy Added Savings on Products and Services Made Available by Horizon

Horizon Direct Access (cont.)Benefits-at-a-GlanceThechartbelowisonlyforillustrativepurposes.Onceyouareenrolled,acompletelistofdetailsandexclusionswillbeprovided in your individual contract/policy.

10 HorizonBlueCrossBlueShieldofNewJersey

Description of service in-network out-of-network Primary Care Physician Copayment* $30copaymentpervisittoselectedPCP.

$50copaymentpervisitifnoPCPisselected.Subjecttoout-of-networkdeductible and50%coinsurance.

Specialist Copayment $50copaymentpervisit. Subjecttoout-of-networkdeductible and50%coinsurance.

Annual Deductible $2,500Individual/$5,000Family(Aggregate). $7,500Individual/$15,000Family(Aggregate).

Coinsurance Planpays70%/Youpay30%. (50%forPrescriptionDrugs).

Planpays50%/Youpay50%.




Inpatient Hospital (Subjecttopreapproval) (includingbiologicallybasedmentalillness) Subjecttoin-networkdeductible

and30%coinsurance.

Subjecttoout-of-networkdeductible and50%coinsurance.

Ambulatory Surgical Center Facility Charges Subjecttoin-networkdeductible and30%coinsurance.


Hospital Outpatient Surgery Facility Charges Subjecttoin-networkdeductible and30%coinsurance.


Emergency Room Copayment $100copayment(waivedifadmittedwithin24hours)isinadditiontoin-networkdeductibleand30%coinsurance.

$100copayment(waivedifadmittedwithin 24hours)isinadditiontoout-of-network deductibleand50%coinsurance.

Alcoholism(Subjecttopreapproval)

Inpatientandoutpatient:Subjecttoin-network deductibleand30%coinsurance.

Inpatient and outpatient: Subject to annual out-of-networkdeductibleand50%coinsurance.

Non-Biologically Based Mental Illness and Substance Abuse •Inpatientconfinement:subjecttopreapproval,limitedto30dayspercalendaryear(1inpatient day may be exchanged for 2 outpatient visits)




Blood/Blood Products/Processing Subjecttoin-networkdeductible and30%coinsurance.


Diagnostic X-ray Determined by place of service. Subjecttoout-of-networkdeductible and50%coinsurance.

Lab Planpays100%whenprovidedbyanetworklab. Subjecttoout-of-networkdeductible and50%coinsurance.







Maternity $25copaymentforinitialofficevisitonly;All otherservicessubjecttoin-networkdeductibleand30%coinsurance.



Notsubjecttodeductible.Coveredat50%coinsurance.

Preventive Care Notsubjecttodeductible,copayment and coinsurance.

Notsubjecttodeductibleandcoinsurance.Maximumof$500perindividual(except newborns)percalendaryear.Newborns: Maximumof$750percalendaryearuptoage1.


Subjecttoin-networkdeductibleand30% coinsurance. Limitedto120dayscombined.



$30copaymentpervisit. Subjecttoout-of-networkdeductible and50%coinsurance.


$30copaymentpervisit. Subjecttoout-of-networkdeductible and50%coinsurance.

HorizonBlueCrossBlueShieldofNewJerseyworkshardtokeepyouhealthy with important savings on products and services beyond your healthcarecoverage.WithourHorizonWellnessDiscounts,† you can save money when you present your plan ID card at the select businesses describedbelowormentionthatyouareaHorizonBCBSNJmember when calling them.

†Pleasenote:Discountprogramsarenotinsured.Theyare“value-added”featuresandmaybeterminatedorchangedwithoutnotice.HorizonBCBSNJassumesnoresponsibilityforanycircumstancesarisingoutoftheuse,misuse,interpretationorapplicationofanyinformation,productsorservicesprovidedbyormadeavailablebythecompaniesspecifiedherein offeringinformation,products,orservicestoyouthroughHorizonWellnessDiscounts.HorizonWellnessDiscountsaremadeavailableforyourconvenienceanddonotconstituteorimplyendorsementofthecompanies,theirinformation,productsorservicesbyHorizonBCBSNJ.

ServicesandproductsprovidedbyHorizonBlueCrossBlueShieldofNewJerseyandHorizonHealthcareofNewJersey,Inc.,anindependentlicenseeoftheBlueCrossand Blue Shield Association. ®RegisteredmarksoftheBlueCrossandBlueShieldAssociation.®´/SMRegisteredandservicemarksofHorizonBlueCrossBlueShieldofNewJersey.SM´RegisteredmarkofSmartEyes.®´´CompleteAdvantagenameisaregisteredtrademarkofDavisVision.Healthyroads,Inc.,isasubsidiaryofAmericanSpecialtyHealthIncorporated(ASH). ©2011AmericanSpecialtyHealthIncorporated.®´´´MedicAlertisafederallyregisteredtrademarkandservicemark.®´´´´WEIGHTWATCHERSistheregisteredtrademarkofWeightWatchersInternationalInc.©2011HorizonBlueCrossBlueShieldofNewJersey,ThreePennPlazaEast,Newark,NewJersey07105

SmartEyesSM´

ThankstoourpartnershipwithEyeMed,youcansaveoneyeglasses,accessoriesandexaminationsthroughthe SmartEyes discount program. Participating locations includeopticaldepartmentsinLensCrafters,Sears Optical,JCPenneyOptical,TargetOptical,andPearleVision,aswellasmanyindependentoptometristand ophthalmologist offices.

Complete Advantage®´´

WiththisprogramthroughDavisVision,youcanenjoydiscountsoneyeglasses,laservisioncorrectionservices,accessories and examinations.

TruVision — Traditional LASIK and Custom LASIK

SaveonLASIKvisionservices,includingapre-operativeexam,surgery,andpost-operativecarethroughTruVision,a national organization that offers board certified eligible ophthalmologists.YoucanalsosavethroughTruVision’sMail Order Contact Lens Program.

HearRx, a HearUSA Company

HearRx,aHearUSACompany,providesdiagnostic audiology services and hearing aid dispensing nationwide.WithlocationsthroughouttheU.S.,it’s easy to visit any center for a test and counseling. Youwillreceivea10%discountonanyhearingaid purchased — even those on sale.

Healthyroads

Healthyroads allows you to save on a variety of health-relatedproducts,includingvitamins,dietary supplements,homeopathicremedies,smokingcessation,weightmanagementandstressreductionprograms, plus much more.

Horizon Alternative Therapies

Receivediscountsonservices includingacupuncture,massage therapy,chiropractic,nutritioncounselingandvitamins.

New York Sports Clubs

ThroughourexclusivearrangementwithNewYorkSportsClubs,youcantakestepstostayhealthybygettingtheexercise you need and you can save money. You’ll pay a discountedinitiationfeeofonly$49,andthelowest corporate monthly dues available.

MedicAlert®´´´

MedicAlert protects and saves lives by providing instant access to identification and critical medical information to first responders in emergency situations. You will receive a free Basic Stainless Steel Bracelet or pendant with free shipping when you enroll.

Weight Watchers®´´´´

Weight Watchers has helped millions of people around theworldloseweight.ReceivediscountsonthreeWeightWatchersprograms,freeregistrationattraditional meetings(inparticipatingareas)andsavingson WeightWatchersOnlineandanat-homekit.

*PrimaryCarePhysician(PCP)selectionrecommendedformaximumbenefits,butnotrequiredandnoreferralneeded.

Page

Introduction 1

Choose the Plan that Works Best for You 2

Before Signing Up for a Plan 3

Horizon Basic and Essential EPO and EPO Plus Benefits 4

Horizon HMO Benefits 6

Horizon Direct Access Benefits 8

Enjoy Added Savings 11

Plan Exclusions 12

Premium Rate Sheet/Enrollment Forms (see back pocket)

Table of

Contents

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