2020 NJ State Health Benets Program (SHBP)
State and State College/University Employees – Plans for CWA Members
Plans effective 1/1/2020 (effective 12/21/2019 for biweekly employees)
1. High Deductible Health Plan. NJ DIRECT HD1500 plan includes $300 Health Savings Account funding by employer.
2. Deductible applies to all services that require a coinsurance.
3. Includes eligible prescription cost share.
4. On select services (durable medical equipment, prosthetics, orthotics, oxygen, private duty nursing, ambulance).
5. Chiropractic: Horizon HMO: 20 visits per calendar year. OMNIA Health Plan: 25 visits per calendar year. All other plans: 30 visits per calendar year.
6. Physical, occupational and speech therapy: OMNIA Health Plan: 30 visit maximum each per calendar year. Horizon HMO: 60 visit combined maximum per calendar year. All other plans based on medical necessity.
7. Laboratory services must be rendered by an in-network participating provider, with some exceptions based on medical policy.
8. Lower copayment applies to children under 19 and physician referrals.
9. $150 per admission does not apply to inpatient childbirth, hospice or inpatient behavioral health/substance use disorder.
OMNIA HEALTH PLAN
Tier 1 Tier 2
IN-NETWORK:
Service Area Available NJ only Nationwide
Specialist Referral No referral required No referral required
Deductible
2
Individual $0 $1,500
Family $0 $3,000
Coinsurance 0% 20% after deductible
Coinsurance Out-of-Pocket Maximum
Individual n/a n/a
Family n/a n/a
Total Out-of-Pocket Maximum (Copay+Deductible+Coinsurance)
Individual $2,500 $4,500
Family $5,000 $9,000
HEALTH CARE SERVICES
Primary Care Ofce Visit $5 $20
Annual Routine Physical (In-Network Only) $0 $0
Specialist Ofce Visit $15 $30
Annual Routine Vision (In-Network Only) $15 $30
Chiropractic
5
$15 $30
Physical/Occupational/Speech Therapy
6
$5 ofce visit/$15 outpatient facility
$20 ofce visit/
20% after deductible at an outpatient facility
DIAGNOSTIC LABORATORY
7
/RADIOLOGY/ADVANCED IMAGING
Outpatient Laboratory/Radiology/Advanced Imaging $15 20% after deductible
Freestanding Laboratory/Radiology/Advanced Imaging $0 $0
EMERGENCY/URGENT MEDICAL SERVICES
Urgent Care Center $15 $30
Emergency Room $100 $100
Ambulance $0 $0
OTHER SERVICES
Inpatient Facility $150 per admission
9
20% after deductible
Outpatient Facility $150 20% after deductible
Outpatient Behavioral Health $15
$30 ofce visit/
20% after deductible at an outpatient facility
Durable Medical Equipment (DME) $0 $0
OUT-OF-NETWORK:
10
Deductible - Individual
No out-of-network benets
Deductible - Family
Coinsurance after Deductible
Out-of-Pocket Coinsurance Maximum - Individual
Out-of-Pocket Coinsurance Maximum - Family
Inpatient Hospital Deductible
OMNIASM Tiered Network Option
HorizonBlue.com/shbp 1-800-414-SHBP (7427)
10. Out-of-network cost basis: CWA Unity DIRECT and CWA Unity 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. If receiving obstetric services prior to 7/1/19, reimbursement will be 195% of CMS fee schedule through the end of obstetric services. NJ DIRECT HD
plans: 90
th
percentile of FAIR Health national benchmark data. All plans with an out-of-network benefit also have specified dollar limits for chiropractic, physical therapy and acupuncture.
11. Out-of-network deductible is combined with in-network deductible.
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.
You can reference the HorizonBlue.com/shbpcalculator to determine your premium contribution.
Horizon Dental Choice plan available. Please visit HorizonBlue.com/SHBP.
Retirees: Please visit state.nj.us/treasury/pensions for information regarding available retiree plans.
CWA UNITY DIRECT
CWA UNITY DIRECT2019
(new hires on or after 7/1/19)
NJ DIRECT HD1500
1
NJ DIRECT HD4000
1
HORIZON HMO
Nationwide Nationwide Nationwide Nationwide NJ and contiguous counties
No referral required No referral required No referral required No referral required Referral required
$0 $100 $1,500
3
$4,000
3
See DME
$0 n/a $3,000
3
$8,000
3
See DME
10%
4
10%
after deductible
4
20% after deductible
3
20%
after deductible
3
0%
$800 $800 $1,000 $1,000 n/a
$2,000 $2,000 $2,000 $2,000 n/a
$6,520 $6,520 $2,500
3
$5,000
3
$6,520
$13,040 $13,040 $5,000
3
$10,000
3
$13,040
$15 $15 20% after deductible 20% after deductible $15
$0 $0 $0 $0 $0
$15 $15 20% after deductible 20% after deductible $15
$15 $15 20% after deductible 20% after deductible $15
$15 $15 20% after deductible 20% after deductible $15
$15 $15 20% after deductible 20% after deductible $15
$0 $0 20% after deductible 20% after deductible $0
$0 $0 20% after deductible 20% after deductible $0
$15 $15 20% after deductible 20% after deductible $15
$150
8
$150
8
20% after deductible 20% after deductible $100
8
10% 10% after deductible 20% after deductible 20% after deductible $0
$0 $0 20% after deductible 20% after deductible $0
$0 $0 20% after deductible 20% after deductible $0
$15 $15 20% after deductible 20% after deductible $15
10% 10% after deductible 20% after deductible 20% after deductible $100 deductible, then covered in full
$400 $400
See in-network deductible
11
See in-network deductible
11
No out-of-network benets
$1,000 $1,000
See in-network deductible
11
See in-network deductible
11
30% 30% 40% 40%
$2,000 $2,000 $3,500 $6,000
$5,000 $5,000 $7,000 $12,000
$500/stay $500/stay n/a n/a
PPO Plan Options
HMO Option
2020 NJ State Health Benets Program (SHBP)
State and State College/University Employees – Plans for CWA Members
Plans effective 1/1/2020 (effective 12/21/2019 for biweekly employees)
(continued)
EC004585B (0220)
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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 plans issued or administered by Horizon BCBSNJ. In the event of a conict between the information contained in this document
and your plan documents, your plan documents shall control.
CWA Unity DIRECT, NJ DIRECT, and OMNIA
SM Health Plans are administered by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) and Horizon HMO is administered by
Horizon Healthcare of New Jersey, Inc. (HHNJ). Both companies are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross
®
and Blue Shield
®
names and
symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon
®
name and symbols are registered marks and OMNIASM is a service mark of Horizon Blue
Cross Blue Shield of New Jersey. © 2020 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and does not discriminate against nor does it exclude people or treat them differently on the
basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benet
determinations. Spanish (Español): Para ayuda en español, llame al 1-866-660-6528 (TTY 711). Chinese (中文): 如需中文協助, 請致電 1-866-660-6528 (TTY 711).
