NJ DIRECT

Check with your employer to find out if all these 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 is available to employees hired prior to 7/1/2019. NJ DIRECT2019 is available to new hires on or after 7/1/2019.

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

Deductible applies to all services that require a coinsurance.

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$0	$100	$0	$0	$0	$0	$200	$1,500*	$4,000*
Family	$0	n/a	$0	$0	$0	$0	$500	$3,000*	$8,000*

IN-NETWORK (IN): Coinsurance

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
	10%¹	10% after deductible¹	10%¹	10%¹	10%¹	10%¹	10%	20% after deductible²	20% after deductible²

¹On select services (durable medical equipment, prosthetics, orthotics, oxygen, private duty nursing, ambulance).
²Includes eligible prescription cost share.

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

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$800	$800	$400	$400	$400	$800	$2,000	$1,000	$1,000
Family	$2,000	$2,000	$1,000	$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	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$6,840	$6,840	$400	$6,840	$6,840	$6,840	$6,840	$2,400*	$2,400*
Family	$13,680	$13,680	$1,000	$13,680	$13,680	$13,680	$13,680	$5,000*	$10,000*

*Includes eligible prescription cost share.

HEALTH CARE SERVICES: Primary Care

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Primary Care Office Visit	$15	$15	$10	$15	$15	$20	$20	20% after deductible	20% after deductible
Annual Routine Physical (In-Network Only)	$0	$0	$0	$0	$0	$0	$0	$0	$0
Direct Primary Care Medical Home (DPCMH)	$0	$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	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Specialist Office Visit	$15	$15	$10	$15	$25	$30/adult $20/child under age 26	$35	20% after deductible	20% after deductible
Annual Routine Vision (In-Network Only)	$15	$15	$10	$15	$25	$30/adult $20/child under age 26	$35	20% after deductible	20% after deductible
Chiropractic	$15	$15	$10	$15	$25	$30/adult $20/child under age 26	$35	20% after deductible	20% after deductible
Physical, Occupational, Speech Therapy	$15	$15	$10	$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	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Outpatient	$0	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible
Freestanding	$0	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible

EMERGENCY/URGENT MEDICAL SERVICES

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Urgent Care Center	$15	$15	$10	$15	$25	$30/adult 20/child under age 26	$35	20% after deductible	20% after deductible
Emergency Room	$150*	$150*	$75*	$100*	$100*	$125	$300	20% after deductible	20% after deductible
Ambulance	10%	10% after deductible	10%	10%	10%	10%	20% after deductible	20% after deductible	20% after deductible

Lower copayment applies to children under 19 and physician referrals.

OTHER SERVICES

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Inpatient Facility	$0	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible
Outpatient Facility	$0	$0	$0	$0	$0	$0	20% after deductible	20% after deductible	20% after deductible
Outpatient Behavioral Health	$15	$15	$10	$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%	10%	20% after deductible	20% after deductible	20% after deductible

OUT-OF-NETWORK (OON): Deductible

Out-of-network cost basis: NJ DIRECT and NJ DIRECT2019: 175% of CMS (Centers for Medicare & Medicaid Services) fee schedule. After out-of-pocket maximum is reached annually, behavioral health is reimbursed at 195% CMS fee schedule. This policy applies through 7/1/21. 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 chiropractic, physical therapy and acupuncture.

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$400	$400	$100	$100	$100	$200	$800	Out-of-network deductible is combined with in-network deductible.	Out-of-network deductible is combined with in-network deductible.
Family	$1,000	$1,000	$250	$250	$250	$500	$2,000	Out-of-network deductible is combined with in-network deductible.	Out-of-network deductible is combined with in-network deductible.

OUT-OF-NETWORK (OON): Coinsurance after Deductible

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	30%	30%	20%	30%	30%	30%	40%	40%	40%

OUT-OF-NETWORK (OON): Out-of-Pocket Coinsurance Maximum

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
Individual	$2,000	$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	$5,000	$12,500	$13,000	$7,000	$12,000

OUT-OF-NETWORK (OON): Inpatient Hospital Deductible

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HD1500	NJDIRECT HD4000
	$500/stay	$500/stay	$200/stay	$200/stay	$200/stay	$500/stay	$600/stay	Not applicable	Not applicable

All 2021 SHBP/SEHBP 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.

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.

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