Health Benefits

Horizon Blue Cross Blue Shield of New Jersey Direct Access Point-of-Service (POS)

The Direct Access Point-of-Service (POS) plan is administered by Horizon Blue Cross Blue Shield of New Jersey. Although the new Horizon Plan does not require referrals, the Plan still requires you to select a Primary Care Physician [PCP]. This plan puts a great emphasis on consultation with your PCP for all care. The PCP will determine whether specialty care is appropriate and in conjunction with Managed Care Protocols so that your claim can be processed properly. This includes the ability to see an in-network specialist outside New Jersey after consultation and approval by your PCP. Co-payments are $10 for a doctor’s office visit and $100 for an Emergency Room (fee waived if admitted).

Horizon members will have access to a toll free 24 hour Nurse Line, 1-888-624-3096, staffed by Registered Nurses to discuss medical concerns.

Under this plan, members may also obtain out of network services from a non-participating provider. However, these services are subject to a deductible of $400 per individual, and a maximum of $800 for all eligible dependents. Maximum out of pocket $5,00/$10,000. Claims will then be paid at 70% of Reasonable and Customary fees as determined by Horizon Blue Cross Blue Shield of New Jersey.

For benefit summary of Horizon BCBSNJ Direct Access POS plan click: Horizon BCBSNJ Plan information

Horizon BCBSNJ OMNIA

The OMNIA plan is administered by Horizon Blue Cross Blue Shield of New Jersey. This plan is a
tiered network plan that encourages you to get care from OMNIA Tier 1 designated doctors,
hospitals and other health care professionals. The plan also covers care provided or arranged by Tier
2 doctors and other health care professionals participating as an In-Network Provider in the Horizon
network of plans. 

The cost sharing (Copayment, Deductible and/or Coinsurance) is lower for use of OMNIA Tier 1 In-
Network Providers than for Tier 2 In-Network Providers. This plan has no out of network benefits.

The Emergency Room fee is $100.00 regardless of hospital affiliation.

Horizon EPO Value Plan

The EPO Plan is administered by Horizon Blue Cross Blue Shield of New Jersey & members must select a Primary Care Physician (PCP). This plan puts a great emphasis on consultation with your PCP for all care. The PCP will determine whether specialty care is appropriate and in conjunction with Managed Care Protocols so that your claim can be processed properly. The EPO Plan uses an extensive network of participating service providers (doctors, hospitals, labs and x-ray groups). All medically necessary care is obtained through your chosen PCP. A referral is not required to visit a specialist. Co-payments are $20 for your PCP visit, $40 for a specialist, $40 for eye exams, (with a $50 reimbursement every 24 months for eyeglasses or contacts) $100 for the Emergency Room (waived if you are admitted). Horizon members will have access to a toll free 24/7 Nurse Line, 1-800-624-3096, staffed by Registered Nurses to discuss any medical concerns you have.

EPO Prescription Drug Plan

The prescription plan is through Express Scripts Inc. Co-payments are as follows:

Retail (30 day supply):

  • $5.00 Generic
  • $20.00 Preferred Brand
  • $35.00 Non-Preferred Brand

Mail (90 day supply):

  • $15.00 Generic
  • $50.00 Preferred Brand
  • $67.50 Non-Preferred Brand

 

QualCare Health Maintenance Organizations (HMO)

The Health Maintenance Organization (HMO) plan is administered by QualCare. The HMO plan uses an extensive network of participating service providers (doctors, hospitals, labs, x-ray groups etc.).  Members must select a Primary Care Physician (PCP).  ALL medically necessary care is obtained through your chosen PCP. There are no referrals required for a specialist. Co-payments are $10 for a doctor’s office visit and $25 for an Emergency Room (fee waived if admitted).

The employee will be responsible for any fees provided by non-participating providers.

Insurance Administrator of America (IAA)

(Not an enrollment option if hired after July 1, 1994) This health plan is the County’s Self Funded Employee Health Benefit Program, which was available to active employees, and eligible retired employees of the County of Monmouth hired prior to July 1, 1994.  Insurance Administrator of America [IAA] administers this Plan. Covered employees are subject to bi-weekly payroll deductions, the amount of which is determined annually. All basic and major medical benefits are subject to the exclusions and limitations described more fully on the IAA website.

Prescription Drug Plan

Monmouth County’s prescription drug plan is administered by Express Scripts. If employees choose to enroll in the prescription plan and they are not enrolled in a health plan there will be a minimal payroll deduction. Medications are dispensed at the pharmacy upon presentation of a doctor’s prescription and a nominal co-payment ($5 for generic and $20 for brand name drugs up to a maximum of 30 - day supply at the pharmacy). 

This plan also provides a Mail order service for medication taken on an ongoing basis. The co-payment under the mail order service is $0 for generic and $15 for brand name, for a maximum 90 - day supply. Most medications are sent via standard shipping by the U.S. Postal Service at no cost to you. 

Page Last Updated: 6/15/2018 3:29:00 PM

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