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NJ PLUS is a point-of-service (POS) plan administered by Horizon Blue Cross Blue Shield of New Jersey. NJ PLUS provides you the best of both worlds: in-network care similar to an HMO plan and out-of-network care similar to a traditional plan. Members that wish to use the in-network level of coverage may select from a vast network of providers and hospitals in a service area covering all of New Jersey, Delaware, Florida, South Carolina, and, Virginia as well as numerous counties in Pennsylvania and New York. Members that wish to use the out-of-network level of coverage, have the freedom to access any eligible provider or hospital of their choice in an unrestricted service area. All providers participating in the NJ PLUS network are carefully selected and screened and must meet rigorous professional standards. Periodically, we review the credentials of participating providers and profile their performance to ensure that members receive the best medical care available.

In-Network Coverage

Upon enrolling, you are encouraged to select a Primary Care Physician (PCP) for yourself and eligible family members. PCPs can be located in any part of the service area and can be different for each family member. You may change your PCP simply by calling Member Services. Your PCP will provide routine care, including annual physical examinations, well-child care and immunizations with an applicable copayment per visit. If you need to see a specialist, your PCP will issue a referral to a participating provider with a $5 copayment per visit. Your PCP will also coordinate your hospital care though the NJ PLUS hospital network and you will receive 100 percent coverage.

Female members have direct access to participating Obstetricians/Gynecologists (OB/GYN) without PCP referral. This includes an annual well woman exam and other OB/GYN related services. A applicable copayment applies per visit, but is waived for prenatal and postnatal maternity care visits after the initial visit.

All members have direct access to a participating optometrist or ophthalmologist for an annual vision examination with a applicable copayment. Additional visits require a PCP referral and a applicable copayment.

Out-of-Network Coverage

When you use out-of-network benefits you incur an annual deductible and coinsurance requirement of 30 percent of reasonable and customary charges. In addition, each out-of-network hospital admission requires a $200 deductible. Preventive care or well care -- except immunizations for children under 12 months, mammographies, and Pap tests - is not covered at the out-of-network level.

Emergency Care

If you experience a medical emergency, please go to the nearest emergency facility immediately regardless of network status. You must contact your PCP and/or NJ PLUS within 48 hours. A $25 copayment applies if you are treated and released but is waived if you are admitted to the hospital. If you do not contact us, coverage will be at 70 percent after an annual deductible. Please note all NJ PLUS PCPs have 24-hour back up coverage in the event he/she is unavailable.

Prescription Drug Coverage - Active Local Employees Without a separate Prescription Drug Program

If you are an active employee and your employer does not offer a separate prescription drug plan, NJ PLUS provides a discounted prescription drug reimbursement program, when you present your discount card to the pharmacist you are charged a reduced fee for your medication and your claim is electronically submitted to the carrier for payment. NJ PLUS will reimburse 90 percent of the cost of prescriptions that are written by your network provider and 70 percent of the cost of prescriptions, less deductibles, written by your out-of-network provider. A mail order service is also provided.

Prescription Drug Coverage - Retirees

Retail Pharmacy - up to 90-day supply copayment amounts

Supply
Generic
Preferred Brand
All Other Brands
01-30 days
$7
$14
$29
31-60 days
$14
$28
$58
61-90 days $21 $42 $87

Mail Order - 90-day supply copayment amounts

Generic
Preferred Brand
All Other Brands
$7
$21
$36

Effective January 1, 2005 there is a $552 annual maximum in prescription drug copayments per person. Once a person has paid $552 in copayments in a calendar year, that person is no longer required to pay any drug copayments for the remainder of that year. Prescription drug copayments are not eligible for reimbursement and do not apply to the NJ PLUS (out-of-network) deductible.

Disease Management Education Programs

NJ PLUS provides disease management education programs for the following: Asthma, Chronic Pulmonary Obstructive Disease, Coronary Artery Disease, Chronic Heart Failure, Chronic Kidney Disease and Diabetes.

Health and Wellness Discount Programs

Horizon BCBSNJ has established relationships with several businesses to provide various discount programs. These programs include but are not limited to the following:

Weight Watchers™ - discounts include tools and support to reach your goals. Call 1-800-651-6000 or 1-800-828-9675.

Health Club Memberships - for discounts at New York Sports Clubs call 1-800-301-1231. For discounts through WellQuest fitness Network call 1-800-595-8448.

SmartEyesSM - discounts on eyeglasses, accessories, and examinations through Cole Managed Vision located at Sears, JCPenney, Target, and Pearle Vision Centers. Call 1-800-424-1155 (use plan number 46492).

Complete Advantage - discounts on laser vision correction services through Davis Vision. Call 1-877-518-8748 (use access code 2410).

HearUSA - discounts on hearing aids. Call 1-800-999-1458.

Horizon Alternative Therapies - discounts on services such as yoga, massage therapy, and acupuncture. Call 1-877-335-2746.

Healthyroads - discounts on vitamins, supplements, smoking cessation programs, and other health-related products. Call 1-877-335-2746.

Precious Additions® - an education and information program for new and expectant parents. Call 1-800-417-SHBP.

To take advantage of these programs, simply present your NJ PLUS ID card at a participating business or mention that you are a Horizon BCBSNJ member when calling. For a complete listing and description of available discount programs, please go to: www.horizonblue.com/discounts

For Additional Information

If you have questions, please call NJ PLUS Member Services at 1-800-414-SHBP (7427) during our service hours of Monday through Friday, 8:00 a.m. to 6:00 p.m. You may also access our interactive Web site at www.horizonblue.com or write to us at:

Horizon Blue Cross Blue Shield of New Jersey
NJ PLUS
PO Box 820
Newark, New Jersey 07101-0820


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