Health Benefits

There are four medical plans types: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), High Deductible Health Plan (HDHP), Tiered-Network Plans. 

Medical plan coverage is provided by: Horizon and Aetna

Enrollment is completed on Benefitsolver.

HMO Plans: Horizon HMO and Aetna HMO

A HMO is a managed care plan that requires the selection of a Primary Care Physician (PCP) from the carrier’s HMO network, who will coordinate all medical care. PCP referrals are required to see Specialists, and there is no out-of-network coverage except for emergencies.  A HMO plan has a deductible and co-insurance, as well as co-pays for doctor’s office and ER visits. HMO plans are best for members who prefer predictable, manageable costs for their health care.

​PPO Plans: 
Horizon - NJ Direct 15, NJ Direct 1525, NJ Direct 2030, and NJ Direct 2035, NJ Direct/NJ Direct 2019

Aetna – Freedom 15, Freedom 1525, Freedom 2030, Freedom 2035, Freedom/Freedom 2019

With a PPO (Participating Provider Organization) plan, there is no requirement to choose a PCP and no referrals are required to see a specialist. There are copayments for PCP and specialist visits, and some services require that coinsurance be paid; Using an out-of-network provider or service costs more out of pocket. PPO plans are best for members who prefer a wider range/variety of doctors over cost.

HDHP Plans: 
Horizon - NJ Direct HDHigh, NJ Direct HDLow
Aetna - Freedom HDLow, Freedom HDHigh
A High Deductible Health Plan (HDHP) is a point-of-service medical plan. The plan deductible must be met before the insurance begins to pay for services. The HDHP is combined with a tax-favored health savings account (HSA) that can be used to pay for qualified medical expenses now (including the medical plan’s deductible) or accumulate over time to pay for future expenses. You determine the amount to fund in your HSA (up to the annual IRS limit). A HDHP (High Deductible Health Plan) plan combines a point-of-service medical plan with a tax-favored health savings account that can be used to pay for qualified medical expenses. The funds in a HSA account may be used to pay for qualified medical expenses now (including the medical plan’s deductible) or accumulate over time to pay for future expenses. HDHP plans are best for members who want greater control over how they manage health care spending.

Tiered-Network Plans: Horizon Omnia and Aetna Liberty Plus
Tiered plans give employees the flexibility to visit practitioners in the carrier’s managed care network, significant premium share reductions and no referrals are required. When utilizing Tier 1 providers there will be lower member cost sharing, with copays as low as $5.00 for an office visit. Tier 1 refers to specific doctors, hospitals and other health care professionals who offer cost-effective care. Tier 2 provides flexibility to see any provider included in the managed care network, but with slightly higher cost sharing. There is no out-of-network coverage with either plan.  

Prescription Drug Plan
Prescription drug coverage begins and ends when health benefits start and terminate. 

The prescription drug plans are administered by OptumRx. Employees may contact OptumRx directly by calling 1-844-368-8740 or visiting their website. 

Retail Pharmacy
Normally, retail pharmacy co-payment amounts are for a 30-day supply. However, you may obtain up to a 90-day supply of your prescription drug. To do so, you must pay two co-payments for a 31- to 60-day supply or three co-payments for a 61- to 90-day supply. Additional information can be found in the “Purchasing Prescription Drugs at a Pharmacy” section.

Waiver of Health Coverage (Medical and Prescription Drug)
If an employee wishes to waive health and prescription drug coverage, they may simply elect “Waive” when they make their benefit plan elections in Benefitsolver. The State Health Benefits medical and prescription drug coverage may be resumed at the next Open Enrollment or through a qualifying life changing event.

The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 requires that most employers sponsoring group health plans offer employees and their eligible dependents the opportunity to temporarily extend their group health coverage in certain instances where coverage under the plan would otherwise end. Examples include: termination of employment, death of an employee, loss of dependent status. For SHBP participants, COBRA is not a separate health program; it is a continuation of SHBP coverage under the provisions of the federal law. Click the link below for more information.

COBRA Information

 NJWELL is an employee wellness program designed to help actively employed members of the State Health Benefits Program (SHBP) live a healthy lifestyle and get rewarded for completing activities designed to promote healthy behaviors. 

http://www.state.nj.us/treasury/pensions/njwell/