| Benefit | NJ FamilyCare Advantage |
|---|
| Acupuncture | Coverage limited to when performed as a form of anesthesia in connection with covered surgery |
| Audiology | Covered |
| Blood and Blood Plasma | Coverage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations |
| Dental | Coverage is limited to preventive dental services (including X-rays and sealants) for children under the age of 12 |
| Diabetic Supplies and Equipment | Covered |
Emergency Medical Care/
Emergency Services | Covered with a $35 copayment |
| EPSDT (Early and Periodic Screening, Diagnosis and Treatment) | Coverage is limited to well-child care, immunizations, lead screening and treatment |
| Family Planning | Coverage includes medical history and physical exams (including pelvic and breast), diagnostic and lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling |
| Home Health & Visiting Nursing Services | Coverage is limited to skilled nursing for homebound member that is provided or supervised by an RN and a home health aide when the purpose of the treatment is skilled care. Coverage includes medical social services that are necessary for treatment of the member's medical condition |
| Hospice Services | Covered, including room and board in an institutional setting |
| Hospital Services (Inpatient) | Covered. Horizon NJ Health is not responsible when the primary admitting diagnosis is mental health or substance abuse related |
| Hospital Services (Outpatient) | Covered with a $5 copayment for each visit |
| Laboratory Services | Covered with a $5 copayment when not part of office visit |
| Maternity Services | Covered, including related newborn care and hearing screening |
| Medical Supplies | Coverage limited to diabetic supplies |
| Nurse Midwife | Covered with a $5 copayment for each visit |
| Nurse Practitioner | Covered with a $5 copayment for each visit |
| Optical Appliances | Members are eligible for eyeglasses or contact lenses every 24 months or more frequently if medically necessary. Members are eligible for eyeglasses or contact lenses from the select assortment of fashion frames or contact lens manufacturers covered by the plan |
| Optometrist Services | Covered for one routine eye exam per year with a $5 copayment per visit |
| Organ Transplants | Coverage is limited to transplant-related physician costs for donor and recipient |
| Outpatient Diagnostic Testing | Covered |
| Podiatrist Services | Covered with a $5 copayment for each visit. Routine hygienic care of feet, including the treatment of corns, calluses, trimming of nails and other hygienic care, in the absence of a pathological condition, is not covered |
| Prescription Drugs from a Retail Pharmacy | Covered with a $1 copayment for generic drugs, $5 copayment for brand name drugs, $10 copayment for a supply of more than 34 days. Atypical antipsychotics and opiate addiction medications such as Suboxone/Subutex and methadone (specifically prescribed for opiate addiction) are not covered |
| Primary Care, Specialty Care and Women's Health Services | Covered with a $5 copayment for each visit |
| Prosthetics | Coverage limited to the initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury or congenital defect. Repair and replacement services are covered when due to congenital growth |
| Radiology Services - Diagnostic & Therapeutic | Covered with a $5 copayment when not part of an office visit |
| Rehabilitation Services - Inpatient | Covered |
| Self-initiated care from a non-participating provider without referral/authorization | The member shall be held responsible for the cost of care |
| Transportation Services | Coverage limited to ambulance for medical emergency only |
