All Other State Members

Check with your employer to find out which plans are available to you.

All of our PPO plans include:

Care in network or out of network in New Jersey, nationwide and abroad
No need to select a Primary Care Physician (PCP)
No referrals necessary to see a specialist
Lower out-of-pocket costs when using the Horizon Managed Care Network or the BlueCard® PPO Network nationwide and Blue Cross Blue Shield Global® Core abroad

NJ DIRECT HD1500 and NJ DIRECT HD4000 are High Deductible Health Plans (HDHPs) that combine a high deductible health plan with a health savings account (HSA). Eligible preventive services are covered at 100% if in network and do not have a deductible. You are responsible for eligible medical and prescription expenses, up to the deductible. NJ DIRECT HD1500 plan includes $300 Health Savings Account funding by employer.

IN-NETWORK (IN): Service Area Available

Nationwide

IN-NETWORK (IN): Specialist Referral

No referral required

IN-NETWORK (IN): Deductible

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$0	$100	$0	$0	$0	$200	$1,500*	$4,000*
Family	$0	Not applicable	$0	$0	$0	$500	$3,000*	$8,000*

IN-NETWORK (IN): Coinsurance

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
	10%²	10% after deductible²	10%²	10%²	10%²	20% after deductible	20% after deductible¹	20% after deductible¹

IN-NETWORK (IN): Coinsurance Out-of-Pocket Maximum

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$800	$800	$400	$400	$800	$2,000	$1,000	$1,000
Family	$2,000	$2,000	$1,000	$1,000	$2,000	$5,000	$2,000	$2,000

IN-NETWORK (IN): Total Out-of-Pocket Maximum (Copay+Deductible+Coinsurance)

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$6,960	$6,960	$6,960	$6,960	$6,960	$6,960	$2,500*	$5,000*
Family	$13,920	$13,920	$13,920	$13,920	$13,920	$13,920	$5,000*	$10,000*

HEALTH CARE SERVICES: Primary Care

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Primary Care Office Visit	$15	$15	$15	$15	$20	$20	20% after deductible	20% after deductible
Annual Routine Physical (In-Network Only)	$0	$0	$0	$0	$0	$0	$0	$0
Direct Primary Care (DPC)	$0	$0	$0	$0	$0	$0	Not available	Not available

HEALTH CARE SERVICES: Horizon CareOnline (Telemedicine)

Cost share may apply

HEALTH CARE SERVICES: Specialist

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Specialist Office Visit	$15	$15	$15	$25	$30/adult $20/child under age 26	$35	20% after deductible	20% after deductible
Annual Routine Vision (In-Network Only)	$15	$15	$15	$25	$30/adult, $20/child under age 26	$35	20% after deductible	20% after deductible
Chiropractic 30 visits per calendar year	$15	$15	$15	$25	$30/adult $20/child under age 26	$35	20% after deductible	20% after deductible
Physical/Occupational/Speech Therapy Based on medical necessity	$15	$15	$15	$25	$30/adult $20/child under age 26	$35 office visit 20% after deductible at an outpatient facility	20% after deductible	20% after deductible

DIAGNOSTIC LABORATORY/RADIOLOGY/ADVANCED IMAGING

Laboratory services must be rendered by an in-network participating provider, with some exceptions based on medical policy.

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Outpatient Laboratory/Radiology/Advanced Imaging	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible
Freestanding Laboratory/Radiology/Advanced Imaging	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible

EMERGENCY/URGENT MEDICAL SERVICES

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Urgent Care Center	$15	$15	$15	$25	$30/adult, $20/child under age 26	$35	20% after deductible	20% after deductible
Emergency Room	$150*	$150*	$100*	$100*	$125	$300	20% after deductible	20% after deductible
Ambulance	10%	10% after deductible	10%	10%	10%	20% after deductible	20% after deductible	20% after deductible

OTHER SERVICES

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Inpatient Facility	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible
Outpatient Facility	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible
Outpatient Behavioral Health	$15	$15	$15	$25	$30/adult $20/child under age 26	$35 office visit 20% after deductible at an outpatient facility	20% after deductible	20% after deductible
Durable Medical Equipment (DME)	10%	10% after deductible	10%	10%	10%	20% after deductible	20% after deductible	20% after deductible

OUT-OF-NETWORK (OON)

Out-of-network cost basis: NJ DIRECT and NJ DIRECT2019: 175% of CMS (Centers for Medicare & Medicaid Services) fee schedule. 90th percentile of FAIR Health national for all other health plans with an out-of-network benefit. All plans with an out-of-network benefit also have specified dollar limits for out-of-network chiropractic ($35), physical therapy ($52) and acupuncture ($60).

	NJDIRECT	NJDIRECT2019	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Deductible
Individual	$400	$400	$100	$100	$200	$800	See in-network deductible*	See in-network deductible*
Family	$1,000	$1,000	$250	$250	$500	$2,000	See in-network deductible*	See in-network deductible*
Coinsurance after Deductible	30%	30%	30%	30%	30%	40%	40%	40%
Out-of-Pocket Coinsurance Maximum
Individual	$2,000	$2,000	$2,000	$2,000	$5,000	$6,500	$3,500	$6,000
Family	$5,000	$5,000	$5,000	$5,000	$12,500	$13,000	$7,000	$12,000
Inpatient Hospital Deductible	$500/stay	$500/stay	$200/stay	$200/stay	$500/stay	$600/stay	Not applicable	Not applicable

Out-of-network deductible is combined with in-network deductible.

All 2022 SHBP/SEHBP medical plans include:

Well Care and Preventive Care: Services such as annual physical and annual gynecological exams, well baby/child medical care and preventive care immunizations are covered 100% when using an in-network doctor.
Behavioral Health and Substance Use Disorder: Counseling services are covered for mental/emotional health and alcohol/substance use disorder.
Horizon Health Guides: Your Horizon Health Guide can help with all your health care needs:
- Answering questions
- Making medical appointments
- Solving issues
- Helping with claims
- Finding care
- Making health and wellness benefit suggestions tailored to you.
Your Horizon Health Guide can connect you with a registered nurse and other resources to help you manage a chronic or complex health condition.
Telemedicine: Talk to a doctor 24/7/365 using Horizon CareOnline℠.
Nurse Chat: Chat with a nurse 24/7 using your computer, mobile device or the Horizon Blue app.
Precious Additions®: A prenatal education program supported by My Health Manager®, powered by WebMD®, gives you access to online tools and resources.

Your health plan may also include care outside of NJ through these options:

BlueCard®: For care in the U.S., Puerto Rico and U.S. Virgin Islands.
Blue Cross Blue Shield Global Core: For care when you travel abroad.
Away From Home Care: Access to care for Horizon HMO members who are away from home.