Horizon Blue Cross Blue Shield of New Jersey

OMNIA Silver Saver HSA ($0 Horizon CareOnline Virtual Care after Ded, $0 Select Insulin, No Referrals)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $2,300 Family: $4,600
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,750 Family: $15,500 Per Person: $7,750
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $20 Copay after deductible
Specialist	Standard: $35 Copay after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: 50% Coinsurance after deductible
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 40% Coinsurance after deductible
Inpatient Services	Standard: 40% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $100 Copay<br>40% Coinsurance after deductible

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