Horizon BCBSNJ Direct Access Plans

Horizon BCBSNJ Direct Access
Low Plan Option/High Plan Option
Rates and Benefits

In-Network: Horizon BCBSNJ's payment for eligible expenses when services are obtained from one of the providers in our Managed Care Network. Horizon BCBSNJ reimburses both Primary Care Physicians and Specialists at the applicable allowance on a fee for service basis. The member will not be responsible for any balance bill. Direct Access provides the highest level of benefits for in-network services and the member does not have to file claims.

Out-of-Network: Horizon BCBSNJ's payment for eligible services that are not obtained from one of the providers in our Managed Care Network. The member may see any physician if he/she is willing to pay a greater share of the costs. Horizon BCBSNJ reimburses participating providers at the applicable allowance. Non-network providers are reimbursed up to our applicable allowance and may balance bill to charges. An annual deductible and coinsurance applies to all eligible medical and most supplemental servicesOnce the member reaches the out of pocket maximum, the Plan pays 100% of the appropriate allowance for eligible services for the rest of the year. There is a lifetime maximum for each member. The member is responsible for complying with all utilization review and cost containment programs.

Direct Access Low Plan Option

Coverage Monthly Premium

Single $322.66

Parent & Children $571.16

Husband & Wife $685.34

Family

$1,018.95

Effective 1/1/2007 to 1/1/2008
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Direct Access High Plan Option

Coverage Monthly Premium

Single $449.26

Parent & Children $724.46

Husband & Wife $956.45

Family

$1,292.48

Effective 1/1/2007 to 1/1/2008
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HORIZON Plans Comparison

FINANCIAL PER CALENDAR YEAR	Low Option			High Option
FINANCIAL PER CALENDAR YEAR	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Deductible - Single	NONE		$2,000	NONE	$1,000
Deductible - Family	NONE		$4,000	NONE	$2,000
Coinsurance	80% - 20%		60% - 40%	NONE	70% - 30%
Maximum Out-of-Pocket Single (Including Deductible)	$5,000 (1)		$10,000 (1)	$3,000 (2)
Maximum Out-of-Pocket Family (Including Deductible)	$10,000 (1)		$20,000 (1)	$7,500 (2)
Office Visit Copay	$20		60% after Deductible	$15	70% after Deductible
Specialist Copay	$40		60% after Deductible	$15	70% after Deductible
Surgery Inpatient Copay	80% - 20%		60% after Deductible	NONE	70% after Deductible
Hospital Inpatient Stay	80% - 20%		60% after Deductible	100%	70% after Deductible
Emergency Room Copay	80% - 20% after $100 Copay			$50
Prescription Drugs (3) Mail Order 2 Copays	$10/$25/$50			$10/$20
Preventive Care Copay	$20/$40		60% NO Deductible	$15	70% NO Deductible
Plan Maximum	Unlimited		Unlimited	Unlimited	Unlimited
HOSPITAL/FACILITY SERVICES
Inpatient Services	Low Option			High Option
Inpatient Services	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Room & Board (semi-private room)	80% - 20%		60% after Deductible	100%	70% after Deductible
Intensive Care & Other Hospital Services (therapy/diagnostic services, blood administration, general nursing, operating room, etc.)	80% - 20%		60% after Deductible	100%	70% after Deductible
Maternity Benefits	80% - 20%		60% after Deductible	100%	70% after Deductible
Organ Transplants (Includes ABMT)	80% - 20%		60% after Deductible	100%	70% after Deductible
Outpatient Services	Low Option			High Option
Outpatient Services	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Hospital Services (therapy/diagnostic services, blood administration, general nursing, operating room, etc)	80% - 20%		60% after Deductible	100%	70% after Deductible
Pre-Admission Testing	80% - 20%		60% after Deductible	100%	70% after Deductible
Medical Emergency/Accidental Injury	80% after $100 copay (copay applies to facility charges)			100% after $50 copay (copay applies to facility charges)
Surgical Center	80% after $100		60% after Deductible	100%	70% after Deductible
Skilled Nursing Facility	80% up to 100 days		60% after Deductible up to 60 days	100% up to 100 days	70% after Deductible up to 60 days
Home Health Care	80% - 20%		60% after Deductible up to 100 visits	100%	70% after Deductible up to 100 visits
Hospice Care	80% - 20% combined $9,000 Lifetime Max		60% after Deductible combined $9,000 Lifetime Max	100% combined $9,000 Lifetime Max	Subject to Deductible & Coinsurance
PHYSICIAN SERVICES
Inpatient Services	Low Option			High Option
Inpatient Services	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Medical Care (including consultations)	80% - 20%		60% after Deductible	100%	70% after Deductible
Surgical Services (including assistant surgeon and anesthesia)	80% - 20%		60% after Deductible	100%	70% after Deductible
Obstetrical Services (i.e., normal delivery, cesarean section, abortion)	80% - 20%		60% after Deductible	100%	70% after Deductible
Diagnostic/Therapy Services	80% - 20%		60% after Deductible	100%	70% after Deductible
Outpatient / Out-of-Hospital Services	Low Option			High Option
	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
	Office	Other	OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Office Visits (including related diagnostic/therapy services) when medically necessary	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
Medical & Surgical Care (including related diagnostic/therapy services)	$20 copay $40 for specialist	80%	60% after Deductible	100% after $15 copay	70% after Deductible
Diagnostic X-ray and Lab	100%	80% (LabCorp @100%)	60% after Deductible	100% after $15 copay	70% after Deductible
Allergy Testing, Treatment & Injections	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
Maternity Care	100% after $20 copay $40 for specialist (first visit only)		60% after Deductible	100% after $15 copay(first visit only)	70% after Deductible
Infertility (includes in-vitro fertilization per NJ Mandate) 4 egg retrievals per lifetime	100% after $20 copay $40 for specialist	80%	60% after Deductible	100% after $15 copay	70% after Deductible
Well Child Care (through age 19)	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
Child Imunizations/Lead Testing (NJ Mandate)	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
Routine Physicals (beginning at age 20) (Health Wellness NJ Mandate) 1 per year	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
Prostrate Screening (NJ Mandate) Men over 40, 1 per year	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
Annual Routine Ob/Gyn Exam 1 exam per year	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
NJ Pap and Mammography Mandates	100% after $20 copay $40 for specialist		60% after Deductible	100% after $15 copay	70% after Deductible
Short Term Therapies: Physical, Speech, Occupational, Respiratory/Inhalation (Limit of 3 modalities per visit) 30 Visit Maximum	100% after $20 copay	80%	60% after Deductible	100% after $15 copay	70% after Deductible
Therapeutic Manipulations $1,000 Individual/$2,000 Family maximum per year. 25 Visits within a 60 day period maximum	100% after $40 copay	80%	60% after Deductible	100% after $15 copay	70% after Deductible
Routine Vision Exam 1 per year	100% after $40 copay		60% after Deductible	100% after $15 copay	70% after Deductible
SUPPLEMENTAL SERVICES
	Low Option			High Option
	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Ambulance (Ground Transport Only)	80% - 20%		60% after Deductible	100%	70% after Deductible
Air Ambulance	80% - 20%		60% after Deductible	100%	70% after Deductible
Private Duty Nursing Limited to 30 visits per year	80% - 20%		60% after Deductible	100%	70% after Deductible
Durable Medical Equipment Combined $2,500 maximum (no maximum on prosthetics)	50% - 50%		60% after Deductible	100%	70% after Deductible
Diabetic Supplies (NJ Mandate)	80% - 20%		60% after Deductible	100%	70% after Deductible
Diabetic Education (NJ Mandate)	100% after $20 copay $40 for specialist		60% after Deductible	100% after applicable copayment	70% after Deductible
Physical Rehabilitation Facility Inpatient Services Limited to 60 days per benefit period	80% - 20%		60% after Deductible	100%	70% after Deductible
Oxygen & Administration	80% - 20%		60% after Deductible	100%	70% after Deductible
Vision Hardware	$100 every 2 Years			$100 every 2 Years
Blood Charges	80% - 20%		60% after Deductible	100%	70% after Deductible
Ambulance Service When Medically Necessary	80% - 20%		60% after Deductible	No Charge	No Charge
MENTAL HEALTH/SUBSTANCE ABUSE All Mental Health/Substance Abuse Care Services must be coordinated through the Horizon BCBSNJ/Magellan Behavioral Health Program. Alcoholism and Biologically Based Mental Illness will be paid as any other medical condition pursuant to the NJ state mandates.
	Low Option			High Option
	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Inpatient Services 90 days per lifetime	80% 45 days per year		60% after Deductible 30 days per year	100% 45 days per year	70% after Deductible 30 days per year
Outpatient Services	80% after $40 copay 50 visits per year 150 visits per lifetime		60% after Deductible 20 days per year 60 visits per lifetime	100% after $15 copay 50 visits per year 150 visits per lifetime	70% after Deductible 20 days per year 60 visits per lifetime
Group Therapy 3 sessions = 1 visit	80% after $40 copay		60% after Deductible	100% after $30 copay	70% after Deductible
Partial Hospitalization 45 days per year	80% - 20% 2 partial days = 1 inpatient day		60% after Deductible	2 partial days = 1 inpatient day	70% after Deductible
COST MANAGEMENT
	Low Option			High Option
	IN NETWORK		OUT OF NETWORK	IN NETWORK	OUT OF NETWORK
Catastrophic Case Management	COVERED		COVERED	COVERED	COVERED
Pre-Admission Review	Physician Network Responsibility In State Member Responsibility Out of State		Member Responsibility 20% reduction for non-compliance	Physician Network Responsibility In State Member Responsibility Out of State	Member Responsibility 20% reduction for non-compliance
ELIGIBILITY Children covered to the end of the calendar year in which they turn 19. Full-time students covered until the end of the calendar year in which they reach 25., or until the end of the month during which their full-time status ends. Handicapped dependents covered beyond the child removal age, if handicap occurred prior to age 19. Dependent children are ineligible for Maternity/Obstetrical Benefits.

NOTES:

All Copayments (except Rx Copays), Deductibles and Coinsurance count towards the Outoof-Pocket Maximum.
The Out-of-Pocket Maximum is combined In and Out-of-Network. All Copayments (except Rx Copays), Deductibles and Coinsurance count towards the Out-of-Pocket Maximum.
At participating pharmacies.

Rate and Comparison charts on this website are provided for informational purposes ONLY and are not to be considered as binding. Not all areas or plans are listed. While every effort is made to maintain the accuracy of this information, you should contact The OSSA Group to confirm rates and coverages available in your area.

If you are a current ROTATOR employee and would like to receive an information pack outlining the specific plans and rates available to you, contact Joe Marini at The OSSA Group, or call 1–800–582–8203 and he will get one in the mail to you.

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ROTATOR Staffing Services, Inc.
P.O. Box 366 - 557 Cranbury Road - East Brunswick, NJ 08816
Phone: (732) 238-6050 - FAX: (732) 238-2152

ROTATOR Staffing Services, Inc. (New York)
Suite 2805 - 122 East 42nd Street - New York, NY 10117
Phone: (212) 601-9500

ROTATOR Staffing Services, Inc. (California)
2076 Westwood Boulevard - Los Angeles CA 90025
Phone: (310) 234-0345 - FAX: (310) 441-3011

Medical Staffing Services, Inc.
P.O. Box 862 - 557 Cranbury Road - East Brunswick, NJ 08816
Phone: (732) 238-6050 - FAX: (732) 238-2152

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