1 HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY

Individual Exchange Products The products offered on and off the Exchange will comply with the Accountable Care Act (ACA) Actuarial Value levels ranging from “bronze” to “gold.” In addition, there will be one product that meets the ACA requirements of a “catastrophic” product, but will be limited to people primarily age 30 and younger. Horizon Blue Cross Blue Shield of New Jersey developed a new insurance product called Horizon Advance EPO. These new products will utilize new network capabilities created by Horizon that narrows the number of eligible Specialists for a member to see and also tiers the in network hospitals. Horizon Advance EPO coverage is effective beginning January 1, Horizon Advance EPO coverage was made available to consumers for review and purchase during the open enrollment period beginning in October 2013.

Health Care Reform and you Our new plans combine the standard essential health benefits, preventive services and call ACA requirements with the features of a Horizon EPO (Exclusive Provider Organization) plan. Horizon Advance EPO Horizon Advantage EPO Horizon Advantage EPO Essential

Hospital and Provider Structure Hospitals The current Horizon Hospital Network identifies hospitals that have opted to participate as Preferred Tier 1 hospitals which will give Horizon Advance EPO members who access care at Preferred Tier 1 hospitals a lower cost share than those who use other hospitals in the network. PCPs – (Internal Medicine, Family Practice, Pediatrics, General Practice, Geriatrics, OB/GYNS) The majority of PCP’s are included. 1 Specialists Will include a subset of Managed Care providers; selection of the subset will be based on 1) cost efficiency metrics; 2) privileges at a Tier 1 hospital; 3) referral patterns to a Preferred Tier 1 hospital; and 4) access requirements. Specialties Not Evaluated: Managed Care providers with specialties outside of the 22 evaluated for efficiency will be automatically included in the network 1. 1 The exception will be providers belonging to a mixed specialty group which was not chosen for inclusion in Horizon Advance EPO.

Evaluated Specialties How were the 22 evaluated specialties providers chosen? Efficiency index calculation and evaluation Referral patterns to Preferred Tier 1 hospitals Privileges at a Tier 1 hospital Geographic access and coverage standards

6 Horizon Advance EPO Key Features PCP selection is required. Referrals and prior authorizations are required. Network Utilizes a subset of Horizon’s Managed Care network. Access to Preferred Tier hospitals. No out-of-network benefits, except in an emergency. No BlueCard access. Horizon Advance EPO was created to comply with the requirements of the Affordable Care Act. Horizon Advance EPO coverage will be effective beginning January 1, Product Prefix JGX, JGW Member Benefits Preventive care – 100% with no out-of-pocket cost when provided by their selected PCP. Vision - limited vision for adults (an eye chart reading at a doctor's office) and full benefits for children under ACA guidelines. Prescriptions - Members must use a participating pharmacy.

7 Horizon Advance EPO Identifying Horizon Advance EPO Providers Horizon Advance EPO providers will be listed on Horizon’s Online Provider Directory with the following indicators: Reimbursement Reimbursement will be at the Managed Care fee schedule. Primary care physicians will be reimbursed based on a fee for service payment methodology. Practitioners participating with Horizon Advance EPO. Practitioners with Preferred Tier 1 hospital affiliations. Preferred Tier 1 hospitals will have a PT1 indicator. All other in-network hospitals without the PT1 symbols are considered Tier 2 hospitals.

Horizon Advance Member Product - Cost Sharing Office VisitsTier 1 hospital place of service and all non-office/non-hospital places of service Tier 2 hospital place of service If a member is seen in an office setting, they are subject to cost sharing dependent upon whether it is the PCP or non-PCP (Ex. $20 PCP copay or $50 non-PCP copay). If a member has a service rendered in a Tier 1 hospital, or any place of service that is not office based and not hospital based (Ex. Freestanding Ambulatory Surgical Center), all facility and professional charges are subject to the “Tier 1” member cost sharing. If a member has a service rendered in a Tier 2 hospital, all facility and professional charges are subject to the “Tier 2”member cost sharing.

9 Horizon Advantage EPO Key Features PCP selection is optional, however lower out-of-pocket costs when certain care is coordinated through a pre-selected PCP. Referrals are not required, but some prior authorizations are required. Network Utilizes the Horizon’s Managed Care network. No out-of-network benefits, except in an emergency. No BlueCard access. Member Benefits Preventive care – 100% with no out-of-pocket cost. Vision - Limited vision coverage is included for children. Prescriptions - Members must use a participating pharmacy. Product Prefix JGZ, JGY Reimbursement Reimbursement will be at the Managed Care fee schedule. Primary care physicians will be reimbursed based on a fee for service payment methodology.

10 Horizon Advantage EPO Essentials Key Features High deductible plan available to individuals ages 30 years and younger or those over 30 years of age who meet certain financial hardship conditions. PCP selection is optional, however lower out-of-pocket costs when certain care is coordinated through a pre-selected PCP. Referrals are not required, but some prior authorizations are required. Network Utilizes the Horizon’s Managed Care network. No out-of-network benefits, except in an emergency. No BlueCard access. Member Benefits Preventive care – 100% with no out-of-pocket cost. Vision - Limited vision coverage is included for children. Prescriptions - Members must use a participating pharmacy. Product Prefix JGZ, JGY Reimbursement Reimbursement will be at the Managed Care fee schedule. Primary care physicians will be reimbursed based on a fee for service payment methodology.

Questions If you have any questions you would like to have addressed during the upcoming Horizon Blue Cross Blue Shield of New Jersey Webinar, please submit them to