HORIZON DIRECT ACCESS DESIGN 10 VERIFICATION

HORIZON DIRECT ACCESS DESIGN 10 VERIFICATION

For complete information and verification of all your benefits, refer to your group health benefits policy. All payments are based on medical necessity and appropriateness of services. Once this balance is met, then all covered members in the family are in benefits. There are two ways a family may meet the family aggregate: 1) Every covered person s contribution goes toward the MOOP before all covered persons are in benefits or 2) One covered person may meet the individual MOOP and be in benefits, while the other covered family members contributions met the balance of the family MOOP. The family Maximum Out of Pocket (MOOP) is two times the individual MOOP and is a family aggregate.

Amounts shown represent individual cost-sharing. The true family aggregate requires the entire family deductible to be met before the covered family members are in benefits. The family deductible is two times the individual deductible and is a true family aggregate. ***All payments based on our allowable amounts. Though the requirement to select a PCP has been eliminated for most services, Horizon BCBSNJ encourages members to select a PCP to coordinate their medical care. ** Selection of a PCP is not a requirement to receive network benefits. Prior authorization may be required for certain services.

These benefit highlights are only a summary of the standard Small Employer Health (SEH) Plan B in a Point of Service format with an office rider offered by Horizon BCBSNJ. Limited to 30 inpatient days per calendar year Limited to 20 outpatient visits per calendar year One inpatient day may be exchanged for two outpatient visits Biologically Based Mental Illness Inpatient 80% after deductible 60% after deductible Outpatient Durable Medical Equipment/ Medical Suppliesģ Horizon MyWay HSA Horizon Direct Access 100/80/60 Benefit Highlights * Other Services (continued) Network Non-Network*** Prescription Drugs 60% after deductible 60% after deductible All MMRx charges accumulate to the network Preapproval may be required Preapproval may be required Maximum Out of Pocket Lifetime Maximum Unlimited Unlimited * This is not a contract. Maternity 80% after deductible 60% after deductible Hospital Outpatient Care 80% after deductible 60% after deductible Outpatient Laboratory/Radiology 80% after deductible 60% after deductible Emergency Room (ER) 80% after deductible 60% after deductible Pre-Admission Testing 80% after deductible 60% after deductible Extended Care/Rehabilitation 80% after deductible 60% after deductible Combined limit of 120 days Must begin within 14 days of preceding hospital stay per calendar year Hospice Care 80% after deductible 60% after deductibleĢ Horizon MyWay HSA Horizon Direct Access 100/80/60 Benefit Highlights * Other Services Network Non-Network*** Ambulatory Surgery 80% after deductible 60% after deductible Therapeutic Manipulations Limit of 30 visits per calendar year combined network and non-network Speech/Cognitive Rehabilitation Therapy Limit of 30 visits per calendar year combined network and non-network Physical/Occupational Therapy Limit of 30 visits per calendar year combined network and non-network Alcoholism Non-Biologically Based Mental Illness and Substance Abuse Inpatient 80% after deductible 60% after deductible Outpatient 80% after deductible 60% after deductible For Non-Biologically Based Mental Illness/Substance Abuse and Alcoholism services, you must call Magellan Behavioral Health at to obtain authorization for inpatient care and a referral for outpatient care to receive the network level of benefits. Surgery 100% after deductible 60% after deductible Radiology 100% after deductible 60% after deductible Laboratory 100% after deductible 60% after deductible Maternity 100% after deductible 60% after deductible Hospital Services Network Non-Network*** Inpatient care 365 days per year Semi-private room or 80% after deductible 60% after deductible intensive care unit. Not subject to deductible and coinsurance. 1 Horizon MyWay HSA Horizon Direct Access 100/80/60 Benefit Highlights * Office Visit Maximum Out of Pocket Plan** Copayment Deductible Network Non-Network Option 1 Not applicable $1,500 $3,500 $5,250 Option 2 Not applicable $2,500 $4,500 $6,750 Network Non-Network*** Coinsurance 100% practitioner services 60% for all services 80% hospital and other settings 60% prescription drugs Practitioner Services Network Non-Network*** Office Visits 100% after deductible 60% after deductible Preventive Care $750 each year per covered dependent child through end of calendar year in which child attains age one $500 maximum per covered person per calendar year.

Horizon direct access design 10