2023 NJ State Health Benets Program (SHBP) State and State College/University Employees
Plans for CWA and Union Negotiated Members
Plans effective 1/1/2023 (effective 12/31/2022 for biweekly employees)
HorizonBlue.com/shbp 1-800-414-SHBP (7427)
OMNIA Tiered Network Option
OMNIA HEALTH PLAN
Tier 1 Tier 2
IN-NETWORK (IN)
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 Not applicable $4,500
Family Not applicable $9,000
Total Out-of-Pocket Maximum (Copay+Deductible+Coinsurance)
Individual $2,500 $4,500
Family $5,000 $9,000
HEALTH CARE SERVICES
Primary Care Ofce Visit $5 $20
Annual Routine Physical (In-Network Only)
$0 $0
Direct Primary Care (DPC) Doctors Ofce $0 $0
First Responders Docs (FRDOCS) $0 $0
Horizon CareOnline (Telemedicine) Cost share may apply Cost share may apply
Specialist Ofce Visit $20 $35
Annual Routine Vision (In-Network Only) $20 $35
Chiropractic
5
$20 $35
Physical/Occupational/Speech Therapy
6
$20 ofce visit/$20 outpatient facility
$35 ofce visit/
20% after deductible at an outpatient facility
DIAGNOSTIC LABORATORY
7
/RADIOLOGY/ADVANCED IMAGING
Outpatient Laboratory/Radiology/Advanced Imaging $20 20% after deductible
Freestanding Laboratory/Radiology/Advanced Imaging $0 $0
EMERGENCY/URGENT MEDICAL SERVICES
Urgent Care Center $35 $50
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 $20
$35 ofce visit/
20% after deductible at an outpatient facility
Durable Medical Equipment (DME) $0 $0
OUT-OF-NETWORK (OON)
10
Deductible - Individual
No out-of-network benets
Deductible - Family
Coinsurance after Deductible
Out-of-Pocket Coinsurance Maximum - Individual
Out-of-Pocket Coinsurance Maximum - Family
Inpatient Hospital Deductible
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.
2023 NJ State Health Benets Program (SHBP) State and State College/University Employees
Plans for CWA and Union Negotiated Members
Plans effective 1/1/2023 (effective 12/31/2022 for biweekly employees)
HorizonBlue.com/shbp 1-800-414-SHBP (7427)
PPO Plan Options
CWA UNITY DIRECT
NJ DIRECT
(employees hired prior to 7/1/19)
CWA UNITY DIRECT2019
NJ DIRECT2019
(new hires on or after 7/1/19)
NJ DIRECT HD1500
1
IN-NETWORK (IN)
Service Area Available Nationwide Nationwide Nationwide
Specialist Referral No referral required No referral required No referral required
Deductible
2
Individual $0 $100 $1,500
3
Family $0 Not applicable $3,000
3
Coinsurance 10%
4
10%
after deductible
4
20% after deductible
3
Coinsurance Out-of-Pocket Maximum
Individual $800 $800 $1,000
Family $2,000 $2,000 $2,000
Total Out-of-Pocket Maximum (Copay+Deductible+Coinsurance)
Individual $7,280 $7,280 $2,500
3
Family $14,560 $14,560 $5,000
3
HEALTH CARE SERVICES
Primary Care Ofce Visit $15 $15 20% after deductible
Annual Routine Physical (In-Network Only)
$0 $0 $0
Direct Primary Care (DPC) Doctors Ofce $0 $0 Not available
First Responders Docs (FRDOCS) $0 $0 $0
Horizon CareOnline (Telemedicine) Cost share may apply Cost share may apply Cost share may apply
Specialist Ofce Visit $30 $30 20% after deductible
Annual Routine Vision (In-Network Only) $30 $30 20% after deductible
Chiropractic
5
$30 $30 20% after deductible
Physical/Occupational/Speech Therapy
6
$30 $30 20% after deductible
DIAGNOSTIC LABORATORY
7
/RADIOLOGY/ADVANCED IMAGING
Outpatient Laboratory/Radiology/Advanced Imaging $0 $0 20% after deductible
Freestanding Laboratory/Radiology/Advanced Imaging $0 $0 20% after deductible
EMERGENCY/URGENT MEDICAL SERVICES
Urgent Care Center $45 $45 20% after deductible
Emergency Room $150
8
$150
8
20% after deductible
Ambulance 10% 10% after deductible 20% after deductible
OTHER SERVICES
Inpatient Facility $0 $0 20% after deductible
Outpatient Facility $0 $0 20% after deductible
Outpatient Behavioral Health $30 $30 20% after deductible
Durable Medical Equipment (DME) 10% 10% after deductible 20% after deductible
OUT-OF-NETWORK (OON)
10
Deductible - Individual $400 $400
See in-network deductible
11
Deductible - Family $1,000 $1,000
See in-network deductible
11
Coinsurance after Deductible 30% 30% 40%
Out-of-Pocket Coinsurance Maximum - Individual $2,000 $2,000 $3,500
Out-of-Pocket Coinsurance Maximum - Family $5,000 $5,000 $7,000
Inpatient Hospital Deductible $500/stay $500/stay Not applicable
10. 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. 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).
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 nj.gov/treasury/pensions/member-guidebooks.shtml for more information.
You can reference the HorizonBlue.com/shbp to determine your premium contribution.
Horizon Dental Choice plan available. Please visit HorizonBlue.com/shbp.
Retirees: Please visit nj.gov/treasury/pensions for information regarding available retiree plans.
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. In the event of a conflict between the information contained in this document and your plan documents, your
plan documents shall control.
2023 NJ State Health Benets Program (SHBP) State and State College/University Employees
Plans for CWA and Union Negotiated Members
Plans effective 1/1/2023 (effective 12/31/2022 for biweekly employees)
HorizonBlue.com/shbp 1-800-414-SHBP (7427)
PPO Plan Options
HMO Option
NJ DIRECT HD4000
1
HORIZON HMO
IN-NETWORK (IN)
Service Area Available Nationwide NJ and contiguous counties
Specialist Referral No referral required Referral required
Deductible
2
Individual $4,000
3
See DME
Family $8,000
3
See DME
Coinsurance 20%
after deductible
3
0%
Coinsurance Out-of-Pocket Maximum
Individual $1,000 Not applicable
Family $2,000 Not applicable
Total Out-of-Pocket Maximum (Copay+Deductible+Coinsurance)
Individual $5,000
3
$7,280
Family $10,000
3
$14,560
HEALTH CARE SERVICES
Primary Care Ofce Visit 20% after deductible $15
Annual Routine Physical (In-Network Only)
$0 $0
Direct Primary Care (DPC) Doctors Ofce Not available Not available
First Responders Docs (FRDOCS) $0 $0
Horizon CareOnline (Telemedicine) Cost share may apply Cost share may apply
Specialist Ofce Visit 20% after deductible $30
Annual Routine Vision (In-Network Only) 20% after deductible $30
Chiropractic
5
20% after deductible $30
Physical/Occupational/Speech Therapy
6
20% after deductible $30
DIAGNOSTIC LABORATORY
7
/RADIOLOGY/ADVANCED IMAGING
Outpatient Laboratory/Radiology/Advanced Imaging 20% after deductible $0
Freestanding Laboratory/Radiology/Advanced Imaging 20% after deductible $0
EMERGENCY/URGENT MEDICAL SERVICES
Urgent Car
e Center 20% after deductible $45
Emergency Room 20% after deductible $100
8
Ambulance 20% after deductible $0
OTHER SERVICES
Inpatient Facility 20% after deductible $0
Outpatient Facility 20% after deductible $0
Outpatient Behavioral Health 20% after deductible $30
Durable Medical Equipment (DME) 20% after deductible $100 deductible, then covered in full
OUT-OF-NETWORK (OON)
10
Deductible - Individual
See in-network deductible
11
No out-of-network benets
Deductible - Family
See in-network deductible
11
Coinsurance after Deductible 40%
Out-of-Pocket Coinsurance Maximum - Individual $6,000
Out-of-Pocket Coinsurance Maximum - Family $12,000
Inpatient Hospital Deductible Not applicable