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 |
¹Includes eligible prescription cost share.
²On select services (durable medical equipment, prosthetics, orthotics, oxygen, private duty nursing, ambulance).
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 | $7,280 | $7,280 | $7,280 | $7,280 | $7,280 | $7,280 | $2,500* | $5,000* |
Family | $14,560 | $14,560 | $14,560 | $14,560 | $14,560 | $14,560 | $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 |
First Responders Docs (FRDOCS) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
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 | $30 | $30 | $15 | $25 | $30/adult $20/child under age 26 |
$35 | 20% after deductible | 20% after deductible |
Annual Routine Vision (In-Network Only) | $30 | $30 | $15 | $25 | $30/adult, $20/child under age 26 | $35 | 20% after deductible | 20% after deductible |
Chiropractic 30 visits per calendar year |
$30 | $30 | $15 | $25 | $30/adult $20/child under age 26 |
$35 | 20% after deductible | 20% after deductible |
Physical/Occupational/Speech Therapy Based on medical necessity |
$30 | $30 | $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 | $45 | $45 | $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 | $30 | $30 | $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.