N.J. Admin. Code § 11:22-5.5

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:22-5.5 - Network copayment

(a) Network copayments in health benefit plans and stand-alone prescription drug plans may not exceed the following amounts:

1. Preventive services, $ 30.00;

2. Primary care provider office visit, $ 50.00;

3. Specialist physician office visit, $ 75.00;

4. Emergency room visit, $ 100.00;

5. Outpatient surgery, $ 500.00;

6. Inpatient admission, $ 500.00 per day up to a maximum of $ 2,500 per admission;

7. Magnetic resonance imaging, computerized axial tomography and positron emission tomography, $ 100.00;

8. Generic drug, $ 25.00 per 30-day supply;

9. Preferred drug, $ 50.00 per 30-day supply;

10. Non-preferred drug, $ 75.00 per 30-day supply; and

11. For any other services and supplies, the copayment is to be determined so that the carrier insures 50 percent or more of the aggregate risk for the service or supply to which the copayment is applied.

(b) Network copayment shall not be applied to any service or supply to which network coinsurance is applied.

N.J. Admin. Code § 11:22-5.5

New Rule, R.2009 d.265, effective 9/8/2009 (operative September 8, 2010).
See: 40 N.J.R. 6915(a), 41 N.J.R. 3302(b).
Former N.J.A.C. 11:22-5.5, Aggregate dollar lifetime benefits maximums, was recodified to N.J.A.C. 11:22-5.7.