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818 Route 202-206, Bridgewater, NJ 08807
Toll Free: 1-800-392-0980, Fax: 1-908-722-2827, E-Mail: info@forefin.com

II) NJ Individual Health Benefits Plan HMO
Standard Plan Descriptions Jump to Rates
This information is for illustrative purposes only - See individual contract for
details and exclusions.
| COVERAGE DESCRIPTION - PLAN HMO STANDARD |
.................... |
Copay Options: ($15/30/40/50) |
| Annual Deductible |
|
$1,000 or $2,500 per person / $2,000 or $5,000 per family |
| Coinsurance |
|
options for 50%, 40%,30%,20% |
| Maximum Annual Coinsurance Limit |
|
No greater than $5,000 |
| Lifetime Maximum |
|
Unlimited |
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| FACILITY BENEFITS |
|
|
| Inpatient Services and Supplies (Subject to pre-approval) |
|
$150/300/400/500 copay per day up to 5 days per admission |
| Inpatient Hospital: Semi-Private |
|
Maximum copay $1,500/3,000/4,000/5,000 per year/per person |
| 365 days per year |
|
|
|
|
|
| Rehabilitation Center Services |
|
Subject to inpatient hospital copayment |
| (Subject to pre-approval) |
|
Copayment will not apply if the admission is immediately preceded by a
hospital inpatient stay |
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|
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| Emergency Room |
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Separate $100 copay |
|
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(waived if admitted, credited toward inpatient |
|
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admission, if admission occurs within 24 hours as a result of the
emergency) |
| Home Health Care (Subject to pre-approval) |
|
Unlimited |
| Skilled Nursing (Subject to pre-approval) |
|
Unlimited |
| Hospice Charges (Subject to pre-approval) |
|
Unlimited |
| Mental/Nervous Health and Substance Abuse |
|
|
| Outpatient (Subject to pre-approval) |
|
$15/30/40/50 copay, maximum 20 visits per year |
| Inpatient (Subject to pre-approval) |
|
$150/300/400/500 copay per day up to 5 days per admission |
|
|
Maximum 30 inpatient 30 inpatient days per year (1 inpatient day may be
exchanged for 2 outpatient visits or partial hospital days); Maximum copay:
$1,500/3,000/4,000/5,000 per year/per person |
| Alcoholism |
|
|
| Outpatient (Subject to pre-approval) |
|
Same as above |
| Inpatient (Subject to pre-approval) |
|
Same as above |
| PROVIDER BENEFITS |
|
|
| Primary (Preventive) Care |
|
$15/30/40/50 copay |
| well baby, routine physical exam, mammography, pap smears,
vaccinations and screenings |
|
|
| Maternity Office Visits |
|
$25 copay initial visit |
| Surgical - Outpatient and Inpatient |
|
$15/30/40/50 copay (Outpatient only) |
| Therapy Services |
|
|
| Inpatient basis only |
|
$15/30/40/50 copay |
|
|
Speech, physical, occupational and cognitive therapies covered for 60
day period per incident of illness or injury (Subject to pre-approval and copay) |
| Chelation, chemotherapy, dialysis, infusion and radiation |
|
Unlimited (Subject to pre-approval and copay) |
|
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| OTHER SERVICES |
|
|
| Prescription |
|
50% coinsurance, for a prescription card, at carrier option |
| Durable Medical Equipment |
|
$15/30/40/50 copay |
| (Subject to pre-approval) |
|
|
| Blood/Blood Products/Processing |
|
|
| Inpatient |
|
Subject to inpatient copay |
|
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As of February 1, 2009
| NJ HMO Monthly Premium |
|
|
|
Husband/ |
|
Parent/ |
|
|
| |
|
Single |
|
Wife |
|
Child |
|
Family |
| $50 Copay |
|
|
|
|
|
|
|
|
| AmeriHealth |
|
$559 |
|
$1,118 |
|
$1,156 |
|
$1,576 |
| HealthNet of NJ |
|
$965 |
|
$1,738 |
|
$1,641 |
|
$2,317 |
|
|
|
|
|
|
|
|
|
| $40 Copay |
|
|
|
|
|
|
|
|
| HealthNet of NJ |
|
$1,055 |
|
$1,898 |
|
$1,793 |
|
$2,532 |
|
|
|
|
|
|
|
|
|
| $30 Copay |
|
|
|
|
|
|
|
|
| Aetna |
|
$926 |
|
$1,852 |
|
$1,668 |
|
$2,768 |
| AmeriHealth |
|
$668 |
|
$1,336 |
|
$1,216 |
|
$1,884 |
| HealthNet of NJ |
|
$1,161 |
|
$2,089 |
|
$1,974 |
|
$2,787 |
| Horizon Blue Cross |
|
$670 |
|
$1,433 |
|
$1,028 |
|
$2,030 |
|
|
|
|
|
|
|
|
|
| $15 Copay |
|
|
|
|
|
|
|
|
| Aetna |
|
$1,359 |
|
$2,717 |
|
$2,448 |
|
$4,061 |
| AmeriHealth |
|
$1,491 |
|
$2,982 |
|
$2,714 |
|
$4,205 |
| HealthNet of NJ |
|
$1,404 |
|
$2,527 |
|
$2,387 |
|
$3,370 |
| CIGNA |
|
$1,257 |
|
$2,425 |
|
$2,262 |
|
$3,493 |
| Horizon Blue Cross |
|
$805 |
|
$1,723 |
|
$1,235 |
|
$2,439 |
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