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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

I) NJ Traditional Plans (Deductible and
Coinsurance) Jump to Rates
This information is for illustrative purposes only - See individual contract for
details and exclusions.
| Annual Deductible |
Individual |
Family (Aggregate) |
|
$2500 |
$5000 |
|
$1,000 |
$1,000 |
|
$1,000 |
$2,000 |
| |
|
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| Coinsurance |
|
|
| CARRIER/INDIVIDUAL |
70/30% or 80/20% |
|
|
|
|
| Maximum Annual Coinsurance Limit |
Individual |
Family |
| 80/20% |
$2,000 |
$4,000 |
| 70/30% |
$2,500 |
$5,000 |
| Lifetime Maximum |
Unlimited |
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| FACILITY BENEFITS |
|
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| Inpatient Hospital: |
Semi-Private - Inpatient Services and Supplies |
|
(Subject to pre-approval) - 365 days per year; |
|
Subject to annual deductible and coinsurance |
Rehabilitation Center Services
not immediately preceded by an inpatient hospital stay (Subject to pre-approval) |
Subject to annual deductible and coinsurance |
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| Emergency Room |
Separate $100 copay |
|
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(if admitted, credited toward inpatient admission); Subject
to annual deductible and coinsurance |
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| Home Health Care (Subject to pre-approval) |
Subject to annual deductible and coinsurance |
| Skilled Nursing (Subject to pre-approval) |
Subject to annual deductible and coinsurance; Limited to 120
days per year in skilled nursing facility |
| Hospice Charges(Subject to pre-approval) |
Subject to annual deductible and coinsurance |
| Mental/Nervous Health and Substance Abuse |
Carrier pays: |
|
| Outpatient/Inpatient (Subject to pre-approval) |
$5,000 combined Annual Maximum; |
|
$25,000 combined Lifetime Maximum; |
|
Subject to annual deductible and coinsurance |
| Alcoholism |
|
|
| Outpatient (Subject to pre-approval) |
Subject to annual deductible and coinsurance |
| Inpatient (Subject to pre-approval) |
Subject to annual deductible and coinsurance |
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| PROVIDER BENEFITS |
|
|
| Primary (Preventive) Care |
Carrier pays: |
|
| well baby, routine physical exam, mammography, pap smears,
vaccinations and screenings |
$500 per individual per year |
No deductible or coinsurance |
|
$500 per year maximum benefit up to age 1 for newborns |
No deductible or coinsurance |
| Maternity Office Visits |
Subject to annual deductible and coinsurance |
| Surgical |
Subject to annual deductible and coinsurance |
|
| Outpatient and Inpatient |
Subject to annual deductible and coinsurance |
| Therapy Services |
30 visits per benefit period |
|
| (Subject to pre-approval) |
Radiation therapy and chemotherapy covered as any other
illness |
|
Infusion therapy |
|
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| OTHER SERVICES |
|
|
| Prescription |
Subject to annual deductible and coinsurance |
| Durable Medical Equipment |
Subject to annual deductible and coinsurance |
| (Subject to pre-approval) |
|
|
| Blood/Blood Products/Processing |
Subject to annual deductible and coinsurance |
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Rates as of January 1, 2007
| Pricing (Monthly Premium) |
|
|
|
|
|
Husband/ |
|
Parent/ |
|
|
| Blue Cross/Blue Shield |
|
Deductible |
|
Single |
|
Wife |
|
Child |
|
Family |
| Coinsurance 70/30 |
|
$2500 |
|
$1,008 |
|
$ 2,404 |
|
$1,788 |
|
$2,524 |
|
|
*2300/4600 |
|
na |
|
na |
|
na |
|
na |
|
|
*1550/3050 |
|
na |
|
na |
|
na |
|
na |
|
|
1000 |
|
1,626 |
|
3,877 |
|
2,885 |
|
4,071 |
| Oxford |
|
$2500 |
|
$781 |
|
$1,561 |
|
$1,444 |
|
$2,224 |
|
|
1000 |
|
1,046 |
|
2,092 |
|
1,935 |
|
2,981 |
| Blue Cross/Blue Shield |
|
Deductible |
|
Single |
|
Wife |
|
Child |
|
Family |
| Coinsurance 80/20 |
|
*$2300/4600 |
|
na |
|
na |
|
na |
|
na |
|
|
*1550/3050 |
|
na |
|
na |
|
na |
|
na |
|
|
$2500 |
|
1,514 |
|
3,047 |
|
2,267 |
|
3,199 |
|
|
1,000 |
|
2,274 |
|
5,422 |
|
4,035 |
|
5,693 |
| Oxford |
|
$2500 |
|
$ 904 |
|
$1,808 |
|
$1,673 |
|
$2,577 |
|
|
1000 |
|
1,231 |
|
2,463 |
|
2,278 |
|
3,509 |

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