NJ Direct 10/Aetna Freedom 10 v. Horizon Direct Access 10 › cms › lib › NJ01000127... · NJ...
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NJ Direct 10/Aetna Freedom 10 v. Horizon Direct Access 10 Brown & Brown Benefit Advisors 1
Transcript of NJ Direct 10/Aetna Freedom 10 v. Horizon Direct Access 10 › cms › lib › NJ01000127... · NJ...
NJ Direct 10/Aetna Freedom 10
v.
Horizon Direct Access 10
Brown & Brown Benefit Advisors 1
In-Network Non-Network In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $0 $100 $0 $100 Family $0 $250 $0 $250
Coinsurance100%;
90% on select services80% of R&C
1 100%;
90% on select services80% of R&C
1
Office Visit Copay2 $10 Primary or Specialist Not applicable $10 Primary or Specialist Not applicable
Annual Out of Pocket Maximum3
Individual $400 $2,000 $400 $2,000
Family $1,000 $5,000 $800 $5,000
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)100% 80% after deductible 100% 80% after deductible
Emergency Room100% after $25 copay
waived if admitted
100% after $25 copay
waived if admitted
100% after $25 copay
waived if admitted
100% after $25 copay
waived if admitted
Ambulance 90% 80% after deductible 90% 80% after deductible
Radiation/Chemotherapy Outpatient 100% 80% after deductible 100% 80% after deductible
X-Ray and Lab Tests 100% 80% after deductible 100% 80% after deductible
100% 80% after deductible 100% 80% after deductible
100% 80% after deductible 100% 80% after deductible
Up 120 days/calendar year Up 60 days/calendar year Up 120 days/calendar year Up 60 days/calendar year
100% 80% after deductible 100% 80% after deductibleHospice
Unlimited Unlimited
Montgomery Township Board of Education
SEHBP NJ Direct 10/Aetna Freedom 10 vs Horizon Direct Access 10
NJ Direct 10/Aetna Freedom 10 Horizon Direct Access Design 7 Education 10
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
NO NO
Unlimited Unlimited
Skilled Nursing Facility
Home Health Care
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Brown & Brown Benefit Advisors 2
In-Network Non-Network In-Network Non-Network
Surgery/Anesthesia 100% 80% after deductible 100% 80% after deductible
Physician Office Visits Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible
Annual Physical Exams 100% No coverage 100% 80% (No deductible)
Annual Well Child Care 100% No coverage 100% 80% (No deductible)
Immunizations (except if travel or job
related)100% No coverage 100% 80% (No deductible)
Annual OB-Gyn Exam 100% 80% (No deductible) 100% 80% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 80% (No deductible) 100% 80% (No deductible)
Annual Prostate screening
(men over 50)100% No coverage 100% 80% (No deductible)
Office Visit copay for 1st prenatal
visit, then 100%80% after deductible
Office Visit copay for 1st prenatal
visit, then 100%80% after deductible
Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible
Allergy Testing and Treatment Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible
Acupuncture Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible
Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible
Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 80% after deductible
100% per hearing aid per 24 months,
for children to age 15
80% after deductible per hearing
aid per 24 months,
for children to age 15
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech) Unlimited Unlimited
NJ Direct 10/Aetna Freedom 10 Horizon Direct Access Design 7 Education 10
$500 maximum every 2 years
Infertility services Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates
Chiropractic Care30 visits per calendar year combined in and out-of-network 30 visits per calendar year combined in and out-of-network
Maternity (including pre-natal)
Includes coverage for child dependents Includes coverage for child dependents
Hearing Aids $1,000 per hearing aid/24 months, for children to age 15
Brown & Brown Benefit Advisors 3
In-Network Non-Network In-Network Non-Network
Durable Medical equipment/Medical
Supplies90% 80% after deductible 90% 80% after deductible
Specialized Non-Standard Infant
Formula90% 80% after deductible 90% 80% after deductible
Inherited Metabolic Disease 90% 80% after deductible 90% 80% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Routine Vision Exam 100% No coverage Office Visit copay 80% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
Children covered to end of year age 26
NJ Direct 10/Aetna Freedom 10 Horizon Direct Access Design 7 Education 10
4Mental health/substance abuse, must be coordinated through the mental health administrator.
Required for certain services Required for certain services
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
3Out-of-Pocket maximum includes deductible, coinsurance and copayments.
Charges in excess of Reasonable and Customary do not count toward out-of-pocket maximum.
2 Copayments apply to in-network primary care and specialist office visit services unless otherwise indicated.
No coverage $50 reimbursement eligible every 24 months
Children covered to end of year age 26
Brown & Brown Benefit Advisors 4
NJ Direct 15/Aetna Freedom 15
v.
Horizon Direct Access 15
Brown & Brown Benefit Advisors 5
In-Network Non-Network In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $0 $100 $0 $100 Family $0 $250 $0 $250
Coinsurance100%;
90% on select services70% of R&C
1 100%;
90% on select services70% of R&C
1
Coinsurance Maximum $400/$10002
Office Visit Copay $15 Primary or Specialist Not applicable $15 Primary or Specialist Not applicable
Annual Out of Pocket Maximum3
Individual $5,720 $2,000 $400 $2,000
Family $11,440 $5,000 $800 $5,000
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)100% 70% after deductible 100% 70% after deductible
Emergency Room100% after $50 copay
waived if admitted
100% after $50 copay
waived if admitted
100% after $50 copay
waived if admitted
100% after $50 copay
waived if admitted
Ambulance 90% 70% after deductible 90% 70% after deductible
Radiation/Chemotherapy Outpatient 100% 70% after deductible 100% 70% after deductible
X-Ray and Lab Tests 100% 70% after deductible 100% 70% after deductible
100% 70% after deductible 100% 70% after deductible
100% 70% after deductible 100% 70% after deductible
Up 120 days/calendar year Up 60 days/calendar year Up 120 days/calendar year Up 60 days/calendar year
100% 70% after deductible 100% 70% after deductible
SEHBP NJ Direct 15/Aetna Freedom 15 vs Horizon Direct Access 15
Unlimited
Montgomery Township Board of Education
NO NO
Horizon Direct Access Design 7 Education 15
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
NJ Direct 15/Aetna Freedom 15
Unlimited
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Unlimited
Skilled Nursing Facility
Unlimited
Home Health Care
Hospice
Brown & Brown Benefit Advisors 6
In-Network Non-Network In-Network Non-Network
Surgery/Anesthesia 100% 70% after deductible 100% 70% after deductible
Physician Office Visits Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Annual Physical Exams 100% No coverage 100% 70% (No deductible)
Annual Well Child Care 100% No coverage 100% 70% (No deductible)
Immunizations (except if travel or job
related)100% No coverage 100% 70% (No deductible)
Annual OB-Gyn Exam 100% 70% (No deductible) 100% 70% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 70% (No deductible) 100% 70% (No deductible)
Annual Prostate screening
(men over 50)100% No coverage 100% 70% (No deductible)
Office Visit copay for 1st prenatal
visit, then 100%70% after deductible
Office Visit copay for 1st prenatal
visit, then 100%70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Allergy Testing and Treatment Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Acupuncture Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 70% after deductible
100% per hearing aid per 24 months,
for children to age 15
70% after deductible per hearing aid per
24 months, for children to age 15$1,000 per hearing aid/24 months, for children to age 15
Unlimited
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech)
$500 maximum every 2 years
Subject to limitations set by NJ MandatesInfertility services
Subject to limitations set by NJ Mandates
Includes coverage for child dependents
Chiropractic Care
Maternity (including pre-natal)
Includes coverage for child dependents
30 visits per calendar year combined in and out-of-network 30 visits per calendar year combined in and out-of-network
NJ Direct 15/Aetna Freedom 15 Horizon Direct Access Design 7 Education 15
Unlimited
Hearing Aids
Brown & Brown Benefit Advisors 7
In-Network Non-Network In-Network Non-Network
Durable Medical equipment/Medical
Supplies90% 70% after deductible 90% 70% after deductible
Specialized Non-Standard Infant
Formula90% 70% after deductible 90% 70% after deductible
Inherited Metabolic Disease 90% 70% after deductible 90% 70% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Routine Vision Exam 100% No coverage Office Visit copay 70% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
4Mental health/substance abuse, must be coordinated through the mental health administrator.
No coverage
Required for certain services
$50 reimbursement eligible ever 24 months
Children covered to end of year age 26
Required for certain services
3Out-of-Pocket maximum includes deductible, coinsurance and copayments. Charges in excess of Reasonable and
Customary do not count toward out-of-pocket maximum.
Horizon Direct Access Design 7 Education 15
Children covered to end of year age 26
2The $400 Individual/$1,000 Family in-network out-of-pocket maximum includes only coinsurance. The in-network coinsurance out-of-pocket amounts met, apply towards out-of-
network out-of-pocket maximum. In addition to the in-network coinsurance out-of-pocket maximum, a maximum out-of-pocket limit of $5,720 individual/$11,440 family, applies to
the plan. In-network coinsurance and copays apply toward this overall in-network maximum out-of-pocket amount. Out-of-Network out-of-pocket includes deductibles and
coinsurance. Charges in excess of Reasonable and Customary do not count toward out of pocket maximum.
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.
1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
NJ Direct 15/Aetna Freedom 15
Brown & Brown Benefit Advisors 8
NJ Direct 1525/Aetna Freedom 1525
v.
Horizon Direct Access 1525
Brown & Brown Benefit Advisors 9
In-Network Non-Network In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $0 $100 $0 $100 Family $0 $250 $0 $250
Coinsurance100%;
90% on select services70% of R&C
1 100%;
90% on select services70% of R&C
1
Coinsurance Maximum $400/$10002
Office Visit Copay $15 Primary/ $25 Specialist Not applicable $15 Primary/ $25 Specialist Not applicable
Annual Out of Pocket Maximum3
Individual $5,720 $2,000 $400 $2,000
Family $11,440 $5,000 $800 $5,000
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)100%
70% after deductible;
subject to $200 copay100%
70% after deductible;
subject to $200 copay
Emergency Room100% after $75 copay
waived if admitted
100% after $75 copay
waived if admitted
100% after $75 copay
waived if admitted
100% after $75 copay
waived if admitted
Ambulance 90% 70% after deductible 90% 70% after deductible
Radiation/Chemotherapy Outpatient 100% 70% after deductible 100% 70% after deductible
X-Ray and Lab Tests 100% 70% after deductible 100% 70% after deductible
100% 70% after deductible 100% 70% after deductible
100% 70% after deductible 100% 70% after deductible
Up 120 days/calendar year Up 60 days/calendar year Up 120 days/calendar year Up 60 days/calendar year
100% 70% after deductible 100% 70% after deductible
NJ Direct 1525/Aetna Freedom 1525
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Montgomery Township Board of Education
SEHBP NJ Direct 1525/Aetna Freedom 1525 vs Horizon Direct Access 15/25
NO
Horizon Direct Access Design 7 $15/$25
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
NO
Home Health CareUnlimited
Unlimited
Unlimited
Skilled Nursing Facility
HospiceUnlimited
Brown & Brown Benefit Advisors 10
In-Network Non-Network In-Network Non-Network
Surgery/Anesthesia 100% 70% after deductible 100% 70% after deductible
Physician Office Visits Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Annual Physical Exams 100% No coverage 100% 70% (No deductible)
Annual Well Child Care 100% No coverage 100% 70% (No deductible)
Immunizations (except if travel or job
related)100% No coverage 100% 70% (No deductible)
Annual OB-Gyn Exam 100% 70% (No deductible) 100% 70% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 70% (No deductible) 100% 70% (No deductible)
Annual Prostate screening
(men over 50)100% No coverage 100% 70% (No deductible)
Office Visit copay for 1st prenatal
visit, then 100%70% after deductible
Office Visit copay for 1st prenatal
visit, then 100%70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Allergy Testing and Treatment Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Acupuncture Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 70% after deductible
100% per hearing aid per 24 months,
for children to age 15
70% after deductible per hearing aid per
24 months, for children to age 15
30 visits per calendar year combined in and out-of-network
Infertility services Subject to limitations set by NJ Mandates
Maternity (including pre-natal)
Includes coverage for child dependents
Hearing Aids $1,000 per hearing aid/24 months, for children to age 15
$500 maximum every 2 years
Subject to limitations set by NJ Mandates
Unlimited
Includes coverage for child dependents
30 visits per calendar year combined in and out-of-network
NJ Direct 1525/Aetna Freedom 1525 Horizon Direct Access Design 7 $15/$25
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech) Unlimited
Chiropractic Care
Brown & Brown Benefit Advisors 11
In-Network Non-Network In-Network Non-Network
Durable Medical equipment/Medical
Supplies90% 70% after deductible 90% 70% after deductible
Specialized Non-Standard Infant
Formula90% 70% after deductible 90% 70% after deductible
Inherited Metabolic Disease 90% 70% after deductible 90% 70% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Routine Vision Exam 100% No coverage Office Visit copay 70% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.
1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
2The $400 Individual/$1,000 Family in-network out-of-pocket maximum includes only coinsurance. The in-network coinsurance out-of-pocket amounts met, apply towards out-of-
network out-of-pocket maximum. In addition to the in-network coinsurance out-of-pocket maximum, a maximum out-of-pocket limit of $5,720 individual/$11,440 family, applies to
the plan. In-network coinsurance and copays apply toward this overall in-network maximum out-of-pocket amount. Out-of-Network out-of-pocket includes deductibles and
coinsurance. Charges in excess of Reasonable and Customary do not count toward out of pocket maximum.
4Mental health/substance abuse, must be coordinated through the mental health administrator.
3Out-of-Pocket maximum includes deductible, coinsurance and copayments. Charges in excess of Reasonable and Customary do not count toward out-of-pocket maximum.
No coverage
Children covered to end of year age 26
$50 reimbursement eligible ever 24 months
Children covered to end of year age 26
Required for certain services
NJ Direct 1525/Aetna Freedom 1525 Horizon Direct Access Design 7 $15/$25
Required for certain services
Brown & Brown Benefit Advisors 12
NJ Direct 2030/Aetna Freedom 2030
v.
Horizon Direct Access 2030
Brown & Brown Benefit Advisors 13
In-Network Non-Network In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $0 $200 $0 $200 Family $0 $500 $0 $500
Coinsurance100%;
90% on select services70% of R&C
1 100%;
90% on select services70% of R&C
1
Coinsurance Maximum $800/$20002
Office Visit Copay $20 Primary/ $30 Specialist Not applicable $20 Primary/ $30 Specialist Not applicable
Annual Out of Pocket Maximum3
Individual $5,720 $5,000 $800 $5,000
Family $11,440 $12,500 $1,600 $12,500
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)100%
70% after deductible;
subject to $500 copay100%
70% after deductible;
subject to $500 copay
Emergency Room100% after $125 copay
waived if admitted
100% after $125 copay
waived if admitted
100% after $100 copay
waived if admitted
100% after $100 copay
waived if admitted
Ambulance 90% 70% after deductible 90% 70% after deductible
Radiation/Chemotherapy Outpatient 100% 70% after deductible 100% 70% after deductible
X-Ray and Lab Tests 100% 70% after deductible 100% 70% after deductible
100% 70% after deductible 100% 70% after deductible
100% 70% after deductible 100% 70% after deductible
Up 120 days/calendar year Up 60 days/calendar year Up 120 days/calendar year Up 60 days/calendar year
100% 70% after deductible 100% 70% after deductible
Montgomery Township Board of Education
SEHBP NJ Direct 2030/Aetna Freedom 2030 vs Horizon Direct Access 20/30
NJ Direct 2030/Aetna Freedom 2030 Horizon Direct Access Design 7 $20/$30
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
NO NO
Unlimited Unlimited
Skilled Nursing Facility
HospiceUnlimited Unlimited
Home Health Care
Brown & Brown Benefit Advisors 14
In-Network Non-Network In-Network Non-Network
Surgery/Anesthesia 100% 70% after deductible 100% 70% after deductible
Physician Office Visits Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Annual Physical Exams 100% No coverage 100% 70% (No deductible)
Annual Well Child Care 100% No coverage 100% 70% (No deductible)
Immunizations (except if travel or job
related)100% No coverage 100% 70% (No deductible)
Annual OB-Gyn Exam 100% 70% (No deductible) 100% 70% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 70% (No deductible) 100% 70% (No deductible)
Annual Prostate screening
(men over 50)100% No coverage 100% 70% (No deductible)
Office Visit copay for 1st prenatal
visit, then 100%70% after deductible
Office Visit copay for 1st prenatal
visit, then 100%70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Allergy Testing and Treatment Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Acupuncture Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Office Visit Copay 70% after deductible Office Visit Copay 70% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 70% after deductible
100% per hearing aid per 24 months,
for children to age 15
70% after deductible per hearing aid per
24 months, for children to age 15
Maternity (including pre-natal)
Includes coverage for child dependents Includes coverage for child dependents
NJ Direct 2030/Aetna Freedom 2030 Horizon Direct Access Design 7 $20/$30
Infertility services Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates
Chiropractic Care30 visits per calendar year combined in and out-of-network 30 visits per calendar year combined in and out-of-network
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech) Unlimited Unlimited
$500 maximum every 2 years
Hearing Aids $1,000 per hearing aid/24 months, for children to age 15
Brown & Brown Benefit Advisors 15
In-Network Non-Network In-Network Non-Network
Durable Medical equipment/Medical
Supplies90% 70% after deductible 90% 70% after deductible
Specialized Non-Standard Infant
Formula90% 70% after deductible 90% 70% after deductible
Inherited Metabolic Disease 90% 70% after deductible 90% 70% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Routine Vision Exam 100% No coverage Office Visit copay 70% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
Children covered to end of year age 26 Children covered to end of year age 26
NJ Direct 2030/Aetna Freedom 2030 Horizon Direct Access Design 7 $20/$30
No coverage $50 reimbursement eligible ever 24 months
4Mental health/substance abuse, must be coordinated through the mental health administrator.
Required for certain services Required for certain services
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.
1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
2The $800 Individual/$2,000 Family in-network out-of-pocket maximum includes only coinsurance. The in-network coinsurance out-of-pocket amounts met, apply towards out-of-
network out-of-pocket maximum. In addition to the in-network coinsurance out-of-pocket maximum, a maximum out-of-pocket limit of $5,720 individual/$11,440 family, applies to
the plan. In-network coinsurance and copays apply toward this overall in-network maximum out-of-pocket amount. Out-of-Network out-of-pocket includes deductibles and
coinsurance. Charges in excess of Reasonable and Customary do not count toward out of pocket maximum.
3Out-of-Pocket maximum includes deductible, coinsurance and copayments. Charges in excess of Reasonable and Customary do not count toward out-of-pocket maximum.
Brown & Brown Benefit Advisors 16
NJ Direct 2035/Aetna Freedom 2035
v.
Horizon Direct Access 2035
Brown & Brown Benefit Advisors 17
In-Network Non-Network In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $200 $800 $200 $800 Family $500 $2,000 $400 $1,600
Coinsurance 80% 60% of R&C 1 80% 60% of R&C
1
Coinsurance Maximum 20% after deductible2
Office Visit Copay $20 Primary/ $35 Specialist Not applicable $20 Primary/ $35 Specialist Not applicable
Annual Out of Pocket Maximum3
Individual $5,720 $6,500 $2,500 $5,000
Family $11,440 $13,000 $5,000 $10,000
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)80%
60% after deductible;
subject to $500 copay80%
60% after deductible;
subject to $500 copay
Emergency Room100% after $300 copay
waived if admitted
100% after $300 copay
waived if admitted
100% after $100 copay
waived if admitted
100% after $100 copay
waived if admitted
Ambulance 80% 60% after deductible 80% 60% after deductible
Radiation/Chemotherapy Outpatient 80% 60% after deductible 80% 60% after deductible
X-Ray and Lab Tests 80% 60% after deductible 80% 60% after deductible
80% 60% after deductible 80% 60% after deductible
80% 60% after deductible 80% 60% after deductible
Up 120 days/calendar year Up 60 days/calendar year Up 120 days/calendar year Up 60 days/calendar year
80% 60% after deductible 80% 60% after deductible
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
NJ Direct 2035/Aetna Freedom 2035 Direct Access 20/35
Montgomery Township Board of Education
SEHBP NJ Direct 2035/Aetna Freedom 2035 vs Horizon Direct Access 20/35
NO NO
Unlimited Unlimited
Skilled Nursing Facility
Home Health Care
HospiceUnlimited Unlimited
Brown & Brown Benefit Advisors 18
In-Network Non-Network In-Network Non-Network
Surgery/Anesthesia 80% 60% after deductible 80% 60% after deductible
Physician Office Visits Office Visit Copay 60% after deductible Office Visit Copay 60% after deductible
Annual Physical Exams 100% No coverage 100% 60% (No deductible)
Annual Well Child Care 100% No coverage 100% 60% (No deductible)
Immunizations (except if travel or job
related)100% No coverage 100% 60% (No deductible)
Annual OB-Gyn Exam 100% 60% (No deductible) 100% 60% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 60% (No deductible) 100% 60% (No deductible)
Annual Prostate screening
(men over 50)100% No coverage 100% 60% (No deductible)
Office Visit copay for 1st prenatal
visit, then 80%60% after deductible
Office Visit copay for 1st prenatal
visit, then 80%60% after deductible
Office Visit Copay 60% after deductible Office Visit Copay 60% after deductible
Allergy Testing and Treatment Office Visit Copay 60% after deductible Office Visit Copay 60% after deductible
Acupuncture Office Visit Copay 60% after deductible Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible Office Visit Copay 60% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 60% after deductible
100% per hearing aid per 24 months,
for children to age 15
60% after deductible per hearing aid per
24 months, for children to age 15
Infertility services Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates
Maternity (including pre-natal)
Includes coverage for child dependents Includes coverage for child dependents
NJ Direct 2035/Aetna Freedom 2035 Direct Access 20/35
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech) Unlimited Unlimited
Chiropractic Care30 visits per calendar year combined in and out-of-network 30 visits per calendar year combined in and out-of-network
$500 maximum every 2 years
Hearing Aids $1,000 per hearing aid/24 months, for children to age 15
Brown & Brown Benefit Advisors 19
In-Network Non-Network In-Network Non-Network
Durable Medical equipment/Medical
Supplies80% 60% after deductible 80% 60% after deductible
Specialized Non-Standard Infant
Formula80% 60% after deductible 80% 60% after deductible
Inherited Metabolic Disease 80% 60% after deductible 80% 60% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
4 Same as any other illness
4 Same as any other illness
4 Same as any other illness
4
Routine Vision Exam 100% No coverage Office Visit copay 60% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
NJ Direct 2035/Aetna Freedom 2035 Direct Access 20/35
No coverage $50 reimbursement eligible ever 24 months
Children covered to end of year age 26 Children covered to end of year age 26
Required for certain services Required for certain services
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.
1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
3 Copayments apply to in-network primary care and specialist office visit services unless otherwise indicated.
2The in-network coinsurance out-of-pocket amounts met, apply towards out-of-network out-of-pocket maximum. In addition to the in-network coinsurance out-of-pocket maximum,
a maximum out-of-pocket limit of $5,720 individual/$11,440 family, applies to the plan. Out-of-Network out-of-pocket includes deductibles and coinsurance. Charges in excess of
Reasonable and Customary do not count toward out of pocket maximum.
4Mental health/substance abuse, must be coordinated through the mental health administrator.
Brown & Brown Benefit Advisors 20
Horizon/Aetna HMO
v.
Horizon POS 10
Brown & Brown Benefit Advisors 21
In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $0 $500 Family $0 $1,000
Coinsurance 100% 60% of R&C 1
Office Visit Copay $10 Primary or Specialist Not applicable
Annual Out of Pocket Maximum2
Individual
Family
Lifetime Maximum Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)100% 60% after deductible
Emergency Room100% after $35 copay
waived if admitted
100% after $35 copay
waived if admitted
Ambulance 100% 60% after deductible
X-Ray and Lab Tests 100% 60% after deductible
100% 60% after deductible
100% 60% after deductible
Up 120 days/calendar year Up 60 days/calendar year
100% 60% after deductibleUnlimited Unlimited
Montgomery Township Board of Education
SEHBP Horizon/Aetna HMO vs Horizon POS Design 10
Horizon HMO/Aetna HMO Horizon POS Design 10
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Inside NJ- Managed Care Network, including contiguous
counties; No Coverage Outside NJ
In-Network
$100 on select services$100 per person on select services
100%
$10 Primary or Specialist
YES
100%
YES
Unlimited Unlimited
Skilled Nursing Facility
$5,720
$11,440
Unlimited
100%
100% after $35 copay
waived if admitted
100%
100%
100%
100%
Up 120 days/calendar year
$3,000 combined INN/OON
$6,000 combined INN/OON
Home Health Care
Hospice
Brown & Brown Benefit Advisors 22
In-Network Non-Network
Surgery/Anesthesia 100% 60% after deductible
Physician Office Visits Office Visit Copay 60% after deductible
Annual Physical Exams 100% 60% (No deductible)
Annual Well Child Care 100% 60% (No deductible)
Immunizations (except if travel or job
related)100% 60% (No deductible)
Annual OB-Gyn Exam 100% 60% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 60% (No deductible)
Annual Prostate screening
(men over 50)100% 60% (No deductible)
Office Visit copay for 1st prenatal
visit, then 100%60% after deductible
Office Visit Copay 60% after deductible
Allergy Testing and Treatment Office Visit Copay 60% after deductible
Acupuncture Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 60% after deductible
100% 60% after deductible
100%
Excluded
100%
100%
100% (no copayment)
100% (no copayment)
100% (no copayment)
100% (no copayment)
Office Visit copay for 1st prenatal visit, then 100%
100%
Office Visit Copay
100% (no copayment)
100% (no copayment)
Horizon HMO/Aetna HMO
Chiropractic Care20 visits max per calendar year 25 visits per calendar year combined in and out-of-network
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech)60 visits combined for physical, occupational, and speech therapies
per calendar year. Subject to office visit copay.60 visits per therapy, subject to office visit copay.
Horizon POS Design 10
$500 max every 2 years;
subject to $100 deductible
In-Network
Hearing Aids $1,000 per hearing aid/24 months, for children to age 15
Maternity (including pre-natal)
Includes coverage for child dependents Includes coverage for child dependents
Infertility services Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates
Office Visit Copay
Brown & Brown Benefit Advisors 23
In-Network Non-Network
Durable Medical equipment/Medical
Supplies100% 60% after deductible
Specialized Non-Standard Infant
Formula100% 60% after deductible
Inherited Metabolic Disease 100% 60% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
3 Same as any other illness
3
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
3 Same as any other illness
3
Routine Vision Exam Office Visit copay 60% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
100% after $100 annual deductible
Horizon HMO/Aetna HMO
No coverage $50 reimbursement eligible ever 24 months
100% after $100 annual deductible
100%
Same as any other illness3
Same as any other illness3
100%
1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
2Out-of-Pocket maximum includes deductible, coinsurance and copayments. In-Network coinsurance applies towards out-of-network coinsurance. Charges in excess of
Reasonable and Customary do not count toward out-of-pocket maximum.
3Mental health/substance abuse, must be coordinated through the mental health administrator.
Children covered to end of year age 26 Children covered to end of year age 26
Required for certain services Required for certain services
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.
In-Network
Horizon POS Design 10
Brown & Brown Benefit Advisors 24
Horizon/Aetna HMO 1525
v.
Horizon POS 1525
Brown & Brown Benefit Advisors 25
In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $0 $500 Family $0 $1,000
Coinsurance 100% 60% of R&C 1
Office Visit Copay $15 Primary/ $25 Specialist Not applicable
Annual Out of Pocket Maximum2
Individual
Family
Lifetime Maximum Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)100% 60% after deductible
Emergency Room100% after $75 copay
waived if admitted
100% after $75 copay
waived if admitted
Ambulance 100% 60% after deductible
X-Ray and Lab Tests 100% 60% after deductible
100% 60% after deductible
100% 60% after deductible
Up 120 days/calendar year Up 60 days/calendar year
100% 60% after deductible
Skilled Nursing Facility100%
Up 120 days/calendar year
Hospice100%
Unlimited Unlimited
$5,720
$11,440
Unlimited
100%
Unlimited
100% after $75 copay
waived if admitted
100%
100%
100%
Unlimited
$3,000 combined INN/OON
$6,000 combined INN/OON
Home Health Care
$15 Primary/ $25 Specialist
100%
Montgomery Township Board of Education
SEHBP Horizon/Aetna HMO 1525 vs Horizon POS Design 10 1525
Horizon/Aetna HMO $15/$25 Horizon POS Design 10 $15/$25
In-Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
YES YES
$100 on select services$100 per person on select services
Brown & Brown Benefit Advisors 26
In-Network Non-Network
Surgery/Anesthesia 100% 60% after deductible
Physician Office Visits Office Visit Copay 60% after deductible
Annual Physical Exams 100% 60% (No deductible)
Annual Well Child Care 100% 60% (No deductible)
Immunizations (except if travel or job
related)100% 60% (No deductible)
Annual OB-Gyn Exam 100% 60% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 60% (No deductible)
Annual Prostate screening
(men over 50)100% 60% (No deductible)
Office Visit copay for 1st prenatal
visit, then 100%60% after deductible
Office Visit Copay 60% after deductible
Allergy Testing and Treatment Office Visit Copay 60% after deductible
Acupuncture Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 60% after deductible
100% 60% after deductibleHearing Aids $1,000 per hearing aid/24 months, for children to age 15
20 visits max per calendar year
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech)
100%
60 visits combined for physical, occupational, and speech therapies
per calendar year. Subject to office visit copay.60 visits per therapy, subject to office visit copay.
30 visits per calendar year combined in and out-of-network
Maternity (including pre-natal)Office Visit copay for 1st prenatal visit, then 100%
Includes coverage for child dependents Includes coverage for child dependents
Infertility services Office Visit Copay
Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates
100%
Excluded
Chiropractic Care100%
100% (no copayment)
100%
Office Visit Copay
100% (no copayment)
100% (no copayment)
100% (no copayment)
100% (no copayment)
100% (no copayment)
Horizon/Aetna HMO $15/$25 Horizon POS Design 10 $15/$25
In-Network
$500 max every 2 years;
subject to $100 deductible
Brown & Brown Benefit Advisors 27
In-Network Non-Network
Durable Medical equipment/Medical
Supplies100% 60% after deductible
Specialized Non-Standard Infant
Formula100% 60% after deductible
Inherited Metabolic Disease 100% 60% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
3 Same as any other illness
3
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
3 Same as any other illness
3
Routine Vision Exam Office Visit copay 60% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
3Mental health/substance abuse, must be coordinated through the mental health administrator.
Required for certain services Required for certain services
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
2Out-of-Pocket maximum includes deductible, coinsurance and copayments. In-Network coinsurance applies towards out-of-network coinsurance. Charges in excess of
Reasonable and Customary do not count toward out-of-pocket maximum.
Horizon/Aetna HMO $15/$25 Horizon POS Design 10 $15/$25
Children covered to end of year age 26 Children covered to end of year age 26
100% after $100 annual deductible
100% after $100 annual deductible
100%
Same as any other illness3
Same as any other illness3
100%
No coverage $50 reimbursement eligible ever 24 months
In-Network
Brown & Brown Benefit Advisors 28
Horizon/Aetna HMO 2030
v.
Horizon POS 2030
Brown & Brown Benefit Advisors 29
In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $0 $500 Family $0 $1,000
Coinsurance 100% 60% of R&C 1
Office Visit Copay $20 Primary/ $30 Specialist Not applicable
Annual Out of Pocket Maximum2
Individual
Family
Lifetime Maximum Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)100% 60% after deductible
Emergency Room100% after $100 copay
waived if admitted
100% after $100 copay
waived if admitted
Ambulance 100% 60% after deductible
X-Ray and Lab Tests 100% 60% after deductible
100% 60% after deductible
100% 60% after deductible
Up 120 days/calendar year Up 60 days/calendar year
100% 60% after deductible
Home Health Care
Skilled Nursing Facility100%
Up 120 days/calendar year
Hospice100%
Unlimited Unlimited
$11,440
Unlimited
100%
Unlimited
100% after $125 copay
waived if admitted
100%
100%
100%
Unlimited
$6,000 combined INN/OON
$5,720
$20 Primary/ $30 ($20 children) Specialist
100%
Montgomery Township Board of Education
SEHBP Horizon/Aetna HMO 2030 vs Horizon POS Design 10 2030
Horizon/Aetna HMO $20/$30 Horizon POS Design 10 $20/$30
In-Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
YES YES
$100 on select services$100 per person on select services
$3,000 combined INN/OON
Brown & Brown Benefit Advisors 30
In-Network Non-Network
Surgery/Anesthesia 100% 60% after deductible
Physician Office Visits Office Visit Copay 60% after deductible
Annual Physical Exams 100% 60% (No deductible)
Annual Well Child Care 100% 60% (No deductible)
Immunizations (except if travel or job
related)100% 60% (No deductible)
Annual OB-Gyn Exam 100% 60% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 60% (No deductible)
Annual Prostate screening
(men over 50)100% 60% (No deductible)
Office Visit copay for 1st prenatal
visit, then 100%60% after deductible
Office Visit Copay 60% after deductible
Allergy Testing and Treatment Office Visit Copay 60% after deductible
Acupuncture Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 60% after deductible
100% 60% after deductibleHearing Aids
20 visits max per calendar year
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech)
100%
60 visits combined for physical, occupational, and speech therapies
per calendar year. Subject to office visit copay.60 visits subject to office visit copay.
$1,000 per hearing aid/24 months, for children to age 15
$500 max every 2 years;
subject to $100 deductible
30 visits per calendar year combined in and out-of-network
Maternity (including pre-natal)Office Visit copay for 1st prenatal visit, then 100%
Includes coverage for child dependents Includes coverage for child dependents
Infertility services Office Visit Copay
Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates
100%
Excluded
Chiropractic Care100%
100% (no copayment)
100%
Office Visit Copay
100% (no copayment)
100% (no copayment)
100% (no copayment)
100% (no copayment)
100% (no copayment)
Horizon/Aetna HMO $20/$30 Horizon POS Design 10 $20/$30
In-Network
Brown & Brown Benefit Advisors 31
In-Network Non-Network
Durable Medical equipment/Medical
Supplies100% 60% after deductible
Specialized Non-Standard Infant
Formula100% 60% after deductible
Inherited Metabolic Disease 100% 60% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
3 Same as any other illness
3
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
3 Same as any other illness
3
Routine Vision Exam Office Visit copay 60% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization Required for certain services Required for certain services
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
Same as any other illness3
Same as any other illness3
100%
No coverage $50 reimbursement eligible ever 24 months
Children covered to end of year age 26 Children covered to end of year age 26
100% after $100 annual deductible
In-Network
100%
4Mental health/substance abuse, must be coordinated through the mental health administrator.
2Out-of-Pocket maximum includes deductible, coinsurance and copayments. In-Network coinsurance applies towards out-of-network coinsurance. Charges in excess of
Reasonable and Customary do not count toward out-of-pocket maximum.
Horizon/Aetna HMO $20/$30 Horizon POS Design 10 $20/$30
100% after $100 annual deductible
Brown & Brown Benefit Advisors 32
Horizon/Aetna HMO 2035
v.
Horizon POS 2035
Brown & Brown Benefit Advisors 33
In-Network Non-Network
Service Areas
Primary Care Physician Referral
Required?
Annual Deductible
Individual $100 $500 Family $250 $1,000
Coinsurance 80% 60% of R&C 1
Coinsurance Maximum $2,000/$5,000
Office Visit Copay $20 Primary/ $35 Specialist Not applicable
Annual Out of Pocket Maximum2
Individual $2,000 $4,000
Family $4,000 $8,000
Lifetime Maximum Unlimited Unlimited
Hospital Inpatient Services (room and
board; physician visits)80% 60% after deductible
Emergency Room100% after $100 copay
waived if admitted
100% after $100 copay
waived if admitted
Ambulance 80% 60% after deductible
X-Ray and Lab Tests 80% 60% after deductible
80% 60% after deductible
80% 60% after deductible
Up 120 days/calendar year Up 60 days/calendar year
80% 60% after deductibleUnlimited
Home Health Care80%
Unlimited
Skilled Nursing Facility80%
Up 120 days/calendar year
Hospice80%
Unlimited
Unlimited
$5,720
$11,440
Unlimited
80%
100% after $300 copay
waived if admitted
80%
80%
$20 Primary/ $35 Specialist
80% after deductible
Montgomery Township Board of Education
SEHBP Horizon/Aetna HMO 2035 vs Horizon POS Design 6 2035
Horizon/Aetna HMO $20/$35 Horizon POS Design 6 $20/$35
In-Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
Inside NJ- Managed Care Network, including contiguous
counties; Outside NJ-Blue Card Network
YES YES
$200 $500
Brown & Brown Benefit Advisors 34
In-Network Non-Network
Surgery/Anesthesia 80% 60% after deductible
Physician Office Visits Office Visit Copay 60% after deductible
Annual Physical Exams 100% 60% (No deductible)
Annual Well Child Care 100% 60% (No deductible)
Immunizations (except if travel or job
related)100% 60% (No deductible)
Annual OB-Gyn Exam 100% 60% (No deductible)
Annual Mammogram
(baseline; women over 40)100% 60% (No deductible)
Annual Prostate screening
(men over 50)100% 60% (No deductible)
Office Visit copay for 1st prenatal
visit, then 80%60% after deductible
Office Visit Copay 60% after deductible
Allergy Testing and Treatment Office Visit Copay 60% after deductible
Acupuncture Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Office Visit Copay 60% after deductible
Wigs (if needed due to specific
diagnosis like Chemo)100% 60% after deductible
100% 60% after deductibleHearing Aids $1,000 per hearing aid/24 months, for children to age 15
Excluded
Chiropractic Care100%
20 visits max per calendar year
$500 max every 2 years;
subject to deductible
30 visits per calendar year combined in and out-of-network
Short Term Therapies (Physical,
Cognitive, Occupational, Respiratory,
Speech)
80%
60 visits combined for physical, occupational, and speech therapies
per calendar year. Subject to office visit copay.60 visits subject to office visit copay.
Includes coverage for child dependents
Infertility services Office Visit Copay
Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates
100%
100% (no copayment)
100% (no copayment)
100% (no copayment)
Maternity (including pre-natal)Office Visit copay for 1st prenatal visit, then 80%
Includes coverage for child dependents
80%
Office Visit Copay
100% (no copayment)
100% (no copayment)
Horizon POS Design 6 $20/$35
100% (no copayment)
Horizon/Aetna HMO $20/$35
In-Network
Brown & Brown Benefit Advisors 35
In-Network Non-Network
Durable Medical equipment/Medical
Supplies80% 60% after deductible
Specialized Non-Standard Infant
Formula80% 60% after deductible
Inherited Metabolic Disease 80% 60% after deductible
Inpatient Mental Illness/Substance
Abuse/Alcohol Treatment Same as any other illness
3 Same as any other illness
3
Outpatient Mental Illness/Substance
Abuse/Alcohol TreatmentSame as any other illness
3 Same as any other illness
3
Routine Vision Exam Office Visit copay 60% after deductible
Vision Hardware
Child Dependent Termination age
Prior-Authorization
2Out-of-Pocket maximum includes deductible, coinsurance and copayments. Charges in excess of Reasonable and Customary do not count toward out-of-pocket maximum.
3Mental health/substance abuse, must be coordinated through the mental health administrator.
$50 reimbursement eligible ever 24 months
Children covered to end of year age 26 Children covered to end of year age 26
Required for certain services Required for certain services
*Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration.
No coverage
80%
Same as any other illness3
Same as any other illness3
100%
1Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances.
Horizon POS Design 6 $20/$35
80%
80%
Horizon/Aetna HMO $20/$35
In-Network
Brown & Brown Benefit Advisors 36
