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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