818 Route 202-206, Bridgewater, NJ 08807
Telephone 908-722-6868, Toll Free: 1-800-392-0980, Fax: 1-908-722-2827, E-Mail: info@forefin.com

New Jersey Small Employer Plans (2-49)

I) HMO with Rider Options

 

 

 

 

 

This information is for illustrative purposes only. See individual contract for details and exclusions.

  Copay Option w/ Rider
REFERRED
FINANCIAL
deductible Single/Family
Coinsurance
Coinsurance Limit: Single/Family
Lifetime Maximum Benefit
N/A
N/A
N/A
N/A
PRIMARY CARE PHYSICIAN VISITS SPECIALTY CARE
Office Visits
Diagnostic Outpatient Testing
Outpatient Therapy
OUTPATIENT SURGERY
$10,$15,20,$25,$30,$40,50 copay
copay per visit
copay per visit
copay per visit
copay per visit
HOSPITALIZATION
Room & /Board (Semi-Private)
Surgery & Anesthesia
Medical & Surgical Specialist Care
Diagnostic Testing

copay per visit
SKILLED NURSING FACILITY
EMERGENCY ROOM
HOME CARE
MATERNITY
First OB Visit
No copay
$50 copay
No copay

$25 copay
MENTAL HEALTH & SUBSTANCE ABUSE
Inpatient

no copay
Maximum of 30
inpatient days
Outpatient copay/visit, 20 visits
PREVENTATIVE CARE
Routine Physicals
Routine GYN Exam
Immunizations
Mammography
CHIROPRACTIC CARE
PRESCRIPTIONS (generic/brand)

copay per visit
copay per visit
copay per visit
copay per visit
Not covered
$5/10/15/20/30 copay

II)Point-of-Service Plans

Open Access (Point-Of-Service Plan) : Visit In-Network physicians without a referral.  No primary physician required.

This information is for illustrative purposes only. See individual contract for details and exclusions.

  Copay Option
w/ Rider In-Network

Out-of-Network
FINANCIAL
deductible: Single
deductible: Family
Coinsurance
Maximum Out-of-Pocket

Lifetime Maximum Benefit

N/A
N/A
N/A
N/A
N/A
N/A

$500/$1,000
$1,000/$2,000
Plan C 70/30 Plan D 80/20
Plan C $3,000
Plan D $2,000
unlimited
PRIMARY CARE PHYSICIAN VISITS
Office Visits
Diagnostic Outpatient Testing
Outpatient Therapy*
OUTPATIENT SURGERY*
$5,$10,$15,$20,$30,$40,$50 copay
copay per visit
copay per visit
copay per visit
copay per visit
subject to deductible & coinsurance
subject to deductible & coinsurance
subject to deductible & coinsurance
subject to deductible & coinsurance
subject to deductible & coinsurance
HOSPITALIZATION*
Room & /Board (Semi-Private)
Surgery & Anesthesia
Medical & Surgical Specialist Care
Diagnostic Testing

no copay

subject to deductible & coinsurance
SKILLED NURSING FACILITY*
EMERGENCY ROOM
HOME CARE*
MATERNITY
First OB Visit
No copay
$50 copay
No copay

$25 copay
subject to deductible & coinsurance

subject to deductible & coinsurance

subject to deductible & coinsurance
MENTAL HEALTH & SUBSTANCE ABUSE
Inpatient

Outpatient*

no copay
Maximum of 30
inpatient days

copay/visit, 20
visits
 
PREVENTATIVE CARE
Routine Physicals
Routine GYN Exam
Immunizations
Mammography
CHIROPRACTIC CARE
PRESCRIPTIONS (generic/brand)

copay per visit
copay per visit
copay per visit
copay per visit
Not covered
$5/10/$15/$20/$30 copay

$500 to age 1
$300 per covered person


30 visits max. deductible & coins.
subject to deductible & coinsurance

* Member pre-certification required or benefits paid will be substantially reduced.

 

For additional information on your insurance needs or information about our Financial Services, call 1-800-392-0980, complete the inquiry request form, or simply E-Mail us at: info@forefin.com.

 

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