NJ DIRECT
For active Employees hired prior to 7/1/20.
IN-NETWORK (IN)
| Benefit | NJ DIRECT10 | NJ DIRECT15 |
| Service Area Available | Nationwide | Nationwide |
| Specialist Referral | No referral required | No referral required |
| Deductible | $0 | $0 |
| Coinsurance (On select services) | 10% | 10% |
| Coinsurance Out-of-Pocket Maximum | ||
| Individual | $400 | $400 |
| Family | $1,000 | $1,000 |
| Total Out-of-Pocket Maximum (Copay+Coinsurance) | ||
| Individual | $400 | $6,960 |
| Family | $1,000 | $13,920 |
HEALTH CARE SERVICES
| Benefit | NJ DIRECT10 | NJ DIRECT15 |
| Primary Care Office Visit | $10 | $15 |
| Annual Routine Physical (In-Network Only) | $0 | $0 |
| Direct Primary Care (DPC) | $0 | $0 |
| Horizon CareOnline (Telemedicine) | Copay may apply | Copay may apply |
| Specialist Office Visit | $10 | $15 |
| Annual Routine Vision (In-Network Only) | $10 | $15 |
| Chiropractic (30 combined IN and OON visits per calendar year) |
$10 | $15 |
| Physical/Occupational/Speech Therapy | $10 | $15 |
| Diagnostic Laboratory/Radiology/Advanced Imaging | $0 | $0 |
EMERGENCY/URGENT MEDICAL SERVICES
| Benefit | NJ DIRECT10 | NJ DIRECT15 |
| Urgent Care Center | $10 | $15 |
| Emergency Room | $25 | $50 |
| Ambulance | 10% | 10% |
OTHER SERVICES
| Benefit | NJ DIRECT10 | NJ DIRECT15 |
| Inpatient Facility | $0 | $0 |
| Outpatient Facility | $0 | $0 |
| Outpatient Behavioral Health | $10 | $15 |
| Durable Medical Equipment (DME) | 10% | 10% |
OUT-OF-NETWORK (OON)
| Benefit | NJ DIRECT10 | NJ DIRECT15 |
| Deductible | ||
| Individual | $100 | $100 |
| Family | $250 | $250 |
| Coinsurance after Deductible | 20% | 30% |
| Out-of-Pocket Coinsurance Maximum | ||
| Individual | $2,000 | $2,000 |
| Family | $5,000 | $5,000 |
| Out-of-Network Fee Schedule | 90th percentile FairHealth | 90th percentile FairHealth |
This document is for informational purposes only and does not constitute a binding agreement. The information provided by this document is not intended to replace or modify the terms, conditions, limitations and exclusions contained within health, dental or vision benefit plans issued or administered by Horizon BCBSNJ. In the event of a conflict between the information contained in this document and your plan documents, your plan documents shall control.
Retirees: Please visit state.nj.us/treasury/pensions for information regarding available retiree plans.
This is not a complete list of all covered services. Exclusions and limitations apply to some services. Visit state.nj.us/treasury/pensions/member-guidebooks.shtml for more information.
