NJ DIRECT - SHBP/SEHBP (2024)

Benefits Overview
Medical Plans
- Local Education Employee Plans
  - NJ DIRECT
  - NJ Educators Health Plan
- Local Government Employee Plans
  - Horizon HMO
  - NJ DIRECT
  - OMNIA℠ Health Plan
- State and State College/University Employees
  - All Other State Members
  - CWA and Union Negotiated Members
  - Horizon HMO
  - OMNIA℠ Health Plan
- Coverage Outside of New Jersey
  - Away From Home Care Program
  - Traveling Abroad
Dental Plans
- Horizon Dental Choice
Plan Benefit Webinars
- Horizon Dental Choice
- Local Education Employees
- Local Government Employee Plans
- State and State College/University Employees
Prescription Drug Coverage
2021 Premium Contribution Calculator
2022 Premium Contribution Calculator
2023 Premium Contribution Calculator
2024 Premium Contribution Calculator
Annual Member Notifications
- Women’s Health and Cancer Rights Act of 1998

Explore your benefits

Learn more about your benefits, including prescription coverage. Visit the N.J. Division of Pensions & Benefits website.

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 HDLow and NJ DIRECT HDHigh 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 HDLow 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 HDLow	NJDIRECT HDHigh
Individual	$0	$100	$0	$0	$0	$0	$200	$1,600*	$4,100*
Family	$0	n/a	$0	$0	$0	$0	$500	$3,200*	$8,200*

IN-NETWORK (IN): Coinsurance

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HDLow	NJDIRECT HDHigh
	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 HDLow	NJDIRECT HDHigh
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 HDLow	NJDIRECT HDHigh
Individual	$7,560	$7,560	$400	$7,560	$7,560	$7,560	$7,560	$2,600*	$5,100*
Family	$15,120	$15,120	$1,000	$15,120	$15,120	$15,120	$15,120	$5,200*	$10,200*

*Includes eligible prescription cost share.

HEALTH CARE SERVICES: Primary Care

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HDLow	NJDIRECT HDHigh
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 (DPC)	$0	$0	$0	$0	$0	$0	$0	Not available	Not available
First Responders Docs (FRDOCS)	$0	$0	$0	$0	$0	$0	$0	$0	$0

HEALTH CARE SERVICES: Horizon CareOnline (Telemedicine)

Cost share may apply

HEALTH CARE SERVICES: Specialist

	NJDIRECT	NJDIRECT2019	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HDLow	NJDIRECT HDHigh
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 HDLow	NJDIRECT HDHigh
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 HDLow	NJDIRECT HDHigh
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 HDLow	NJDIRECT HDHigh
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. 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	NJDIRECT10	NJDIRECT15	NJDIRECT1525	NJDIRECT2030	NJDIRECT2035	NJDIRECT HDLow	NJDIRECT HDHigh
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 HDLow	NJDIRECT HDHigh
Individual	30%	30%	20%	30%	30%	30%	40%	40%	40%
Out-of-Pocket Coinsurance Maximum - Individual	$2,000	$2,000	$2,000	$2,000	$2,000	$5,000	$6,500	$3,600	$6,100
Out-of-Pocket Coinsurance Maximum - Family	$5,000	$5,000	$5,000	$5,000	$5,000	$12,500	$13,000	$7,200	$12,200

All 2024 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.
Telemedicine: Talk to a doctor 24/7/365 usingHorizon CareOnline℠.
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 Member Services 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.