CWA and Union Negotiated 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)

	CWA UNITY DIRECT NJ DIRECT	CWA UNITY DIRECT2019 NJ DIRECT2019	NJ DIRECT HD1500	NJ DIRECT HD4000
Service Area Available	Nationwide	Nationwide	Nationwide	Nationwide
Specialist Referral	No referral required	No referral required	No referral required	No referral required
Deductible Deductible applies to all services that require a coinsurance.
Individual	$0	$100	$1,500¹	$4,000¹
Family	$0	Not applicable	$3,000¹	$8,000¹
Coinsurance	10%²	10% after deductible²	20% after deductible¹	20% after deductible¹
Coinsurance Out-of-Pocket Maximum
Individual	$800	$800	$1,000	$1,000
Family	$2,000	$2,000	$2,000	$2,000
Total Out-of-Pocket Maximum (Copay+Deductible+Coinsurance)
Individual	$6,840	$6,840	$2,500¹	$5,000¹
Family	$13,680	$13,680	$5,000¹	$10,000¹

HEALTH CARE SERVICES

	CWA UNITY DIRECT NJ DIRECT	CWA UNITY DIRECT2019 NJ DIRECT2019	NJ DIRECT HD1500	NJ DIRECT HD4000
Primary Care Office Visit	$15	$15	20% after deductible	20% after deductible
Annual Routine Physical (In-Network Only)	$0	$0	$0	$0
Direct Primary Care Medical Home (DPCMH)	$0	$0	Not available	Not available
Horizon CareOnline (Telemedicine)	Cost share may apply	Cost share may apply	Cost share may apply	Cost share may apply
Specialist Office Visit	$15	$15	20% after deductible	20% after deductible
Annual Routine Vision (In-Network Only)	$15	$15	20% after deductible	20% after deductible
Chiropractic 30 visits per calendar year	$15	$15	20% after deductible	20% after deductible
Physical/Occupational/Speech Therapy Based on medical necessity	$15	$15	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.

	CWA UNITY DIRECT NJ DIRECT	CWA UNITY DIRECT2019 NJ DIRECT2019	NJ DIRECT HD1500	NJ DIRECT HD4000
Outpatient Laboratory/Radiology/Advanced Imaging	$0	$0	20% after deductible	20% after deductible
Freestanding Laboratory/Radiology/Advanced Imaging	$0	$0	20% after deductible	20% after deductible

EMERGENCY/URGENT MEDICAL SERVICES

	CWA UNITY DIRECT NJ DIRECT	CWA UNITY DIRECT2019 NJ DIRECT2019	NJ DIRECT HD1500	NJ DIRECT HD4000
Urgent Care Center	$15	$15	20% after deductible	20% after deductible
Emergency Room	$150*	$150*	20% after deductible	20% after deductible
Ambulance	10%	10% after deductible	20% after deductible	20% after deductible

OTHER SERVICES

	CWA UNITY DIRECT NJ DIRECT	CWA UNITY DIRECT2019 NJ DIRECT2019	NJ DIRECT HD1500	NJ DIRECT HD4000
Inpatient Facility	$0	$0	20% after deductible	20% after deductible
Outpatient Facility	$0	$0	20% after deductible	20% after deductible
Outpatient Behavioral Health	$15	$15	20% after deductible	20% after deductible
Durable Medical Equipment (DME)	10%	10% after deductible	20% after deductible	20% after deductible

OUT-OF-NETWORK (OON)

	CWA UNITY DIRECT NJ DIRECT	CWA UNITY DIRECT2019 NJ DIRECT2019	NJ DIRECT HD1500	NJ DIRECT HD4000
Deductible
Individual	$400	$400	See in-network deductible Out-of-network deductible is combined with in-network deductible	See in-network deductible Out-of-network deductible is combined with in-network deductible
Family	$1,000	$1,000	See in-network deductible Out-of-network deductible is combined with in-network deductible	See in-network deductible Out-of-network deductible is combined with in-network deductible
Coinsurance after Deductible	30%	30%	40%	40%
Out-of-Pocket Coinsurance Maximum
Individual	$2,000	$2,000	$3,500	$6,000
Family	$5,000	$5,000	$7,000	$12,000
Inpatient Hospital Deductible	$500/stay	$500/stay	Not applicable	Not applicable

Out-of-network cost basis:

CWA Unity DIRECT, CWA Unity DIRECT2019, 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.
NJ DIRECT HD plans: 90th percentile of FAIR Health national benchmark. 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).

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.

Need help?

Call your Horizon Health Guide at 1-800-414-SHBP (7427), weekdays, from 8 a.m. to 6 p.m., Eastern Time (ET), or sign in to chat or send an email. You can use the Horizon Blue app, too!

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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