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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021 - 12/31/2021Horizon BCBSNJ: State Health Benefits Program- NJ DIRECT 2035 (PPO)Coverage for: All Coverage TypesPlan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and theplan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) willbe provided separately. This is only a summary. Benefits may change upon renewal. For more information about your coverage, or to get acopy of the complete terms of coverage, visit Member Online Services at http://www.nj.gov/treasury/pensions/index.shtml or by calling 1-609292-7524. If you do not currently have coverage with Horizon BCBSNJ you can view a sample policy ml. For general definitions of common terms, such as allowed amount, balance billing,coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.cciio.cms.gov orcall 1-609-292-7524 to request a copy.Important QuestionsWhat is the overalldeductible?AnswersWhy This Matters: 200.00 Individual/ 500.00 Family Generally, you must pay all of the costs from providers up to the deductible amountfor in-network services that do not before this plan begins to pay. If you have other family members on the plan, eachfamily member must meet their own individual deductible until the total amount ofrequire a copayment. 800.00Individual/ 2,000.00 Family for out- deductible expenses paid by all family members meets the overall family deductible.of-network providers. Aggregatefamily.Are there services covered Yes. Preventive care is covered before This plan covers some items and services even if you haven’t yet met the deductiblebefore you meet youryou meet your deductible.amount. But a copayment or coinsurance may apply. For example, this plan coversdeductible?certain preventive services without cost-sharing and before you meet yourdeductible. See a list of covered preventive services are-benefits/.Are there other deductibles No.You don’t have to meet deductibles for specific services.for specific services?What is the out-of-pocket Yes, In-network coinsurance limitThe out-of-pocket limit is the most you could pay in a year for covered services. Iflimit for this plan?you have other family members in this plan, they have to meet their own out-of 2,000.00 Individual/ 5,000.00pocket limits until the overall family out-of-pocket limit has been met.Family; Active employee in-networkHealth providers 6,840.00Individual / 13,680.00 Family. Outof-network Health providers 6,500.00 Individual / 13,000.00Family.What is not included in the Premiums, balance-billing charges and Even though you pay these expenses, they don’t count toward the out-of-pocketout-of-pocket limit?health care this plan doesn’t cover.limit.Will you pay less if you use Yes. For a list of in-networkThis plan uses a provider network. You will pay less if you use a provider in thea network provider?providers, seeplan's network. You will pay the most if you use an out-of-network provider, andwww.HorizonBlue.com/shbp or you might receive a bill from a provider for the difference between the provider'scall 1-800-414-SHBP (7427).charge and what your plan pays (balance billing). Be aware your network providermight use an out-of-network provider for some services (such as lab work). Checkwith your provider before you get services.(NJ DIRECT (PPO))/BlueCard1 of 9

Do you need a referral toNo.You can see the specialist you choose without a referral.see a specialist?All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedIf you visit a health Primary care visit to treat ancare provider’s office injury or illnessor clinicIf you have a testIf you need drugs totreat your illness orconditionWhat You Will PayNetwork ProviderOut-of-Network(You will pay theProvider(You will payleast)the most) 20.00 Copayment per40% Coinsurance.visit. Deductible does notapply.Limitations, Exceptions, & OtherImportant InformationOut-of-network coverage forchiropractic and acupuncture servicesare limited to no more than 35 a visitfor chiropractic and 60 a visit foracupuncture or 75% of the in networkcost per visit, whichever is less.Specialist visit 35.00 Copayment per40% Coinsurance.visit. Deductible does notapply.Preventivecare/screening/immunizationNo Charge. Deductibledoes not apply.Not Covered.One per calendar year. You may haveto pay for services that aren'tpreventive. Ask your provider if theservices needed are preventive. Thencheck what your plan will pay for.Diagnostic test (x-ray, bloodwork)20% Coinsurance.40% Coinsurance.Imaging (CT/PET scans, MRIs) 20% Coinsurance.40% Coinsurance.Requires pre-approval.Generic drugsnonenonenonePreferred brand drugsMore information about Non-preferred brand drugsprescription drugcoverage is availablethrough your employer. Specialty drugsSee separate Prescription Drug Plan SBCIf you haveoutpatient surgery20% Coinsurance.Facility fee (e.g., ambulatorysurgery center)40% Coinsurance.* For more information about limitations and exceptions, see the plan or policy document athttp://www.nj.gov/treasury/pensions/index.shtml2 of 9

CommonMedical EventServices You May NeedPhysician/surgeon feesIf you needimmediate medicalattentionIf you have ahospital stayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesWhat You Will PayLimitations, Exceptions, & OtherNetwork ProviderOut-of-NetworkImportant Information(You will pay theProvider(You will payleast)the most)20% Coinsurance.20% Coinsurance for in-network40% Coinsurance.anesthesia.Emergency room care 300.00 Copayment pervisit for OutpatientHospital. Deductible doesnot apply. 300.00 Copayment perIf admitted within 24 hours, thevisit for Outpatientcopayment is waived. Payment at theHospital. Deductible doesin-network level applies only to truenot apply.Medical Emergencies & AccidentalInjuries.Emergency medicaltransportation20% Coinsurance.40% Coinsurance.Urgent care 35.00 Copayment per40% Coinsurance.visit. Deductible does notapply.Limited to local emergency transport tothe nearest facility equipped to treat theemergency condition.noneFacility fee (e.g., hospital room) 20% Coinsurance.40% Coinsurance.Requires pre-approval. There is aseparate 600 deductible per inpatientstay for out-of-network facilities.Physician/surgeon fees20% Coinsurance.40% Coinsurance.Requires pre-approval. 20%Coinsurance for in-network anesthesia.Outpatient services 35.00 Copayment perOffice visit. Deductibledoes not apply.20% Coinsurance forOutpatient Hospital.40% Coinsurance.Some specialty outpatient servicesrequire pre-approval.Inpatient services20% Coinsurance.40% Coinsurance.Requires pre-approval. There is aseparate 600 deductible per inpatientstay for out-of-network facilities.* For more information about limitations and exceptions, see the plan or policy document athttp://www.nj.gov/treasury/pensions/index.shtml3 of 9

CommonMedical EventIf you are pregnantIf you need helprecovering or haveother special healthneedsServices You May NeedOffice visitsWhat You Will PayNetwork ProviderOut-of-Network(You will pay theProvider(You will payleast)the most) 20.00 Copayment per visit 40% Coinsurance.for Office. 35.00Copayment per visit forSpecialist. Deductible doesnot apply.Limitations, Exceptions, & OtherImportant InformationCost sharing does not apply forpreventive services. Maternity care mayinclude tests and services describedelsewhere in the SBC (i.e. Ultrasound.)Childbirth/delivery professional 20% Coinsurance.services40% Coinsurance.Childbirth/delivery facilityservices20% Coinsurance.40% Coinsurance.Requires pre-approval. There is aseparate 600 deductible per inpatientstay for out-of-network facilities.Home health care20% Coinsurance.40% Coinsurance.Requires pre-approval.Rehabilitation servicesRequires pre-approval. There is aseparate 600 deductible per inpatientstay for out-of-network facilities.Skilled nursing care 35.00 Copayment per visit 40% Coinsurance.for Office. Deductible doesnot apply.20% Coinsurance forInpatient and OutpatientFacility. 35.00 Copayment per visit 40% Coinsurance.for Office. Deductible doesnot apply.20% Coinsurance forInpatient and OutpatientFacility.20% Coinsurance.40% Coinsurance.Durable medical equipment20% Coinsurance.Requires pre-approval for all rentalsand some purchases.Habilitation services40% Coinsurance.* For more information about limitations and exceptions, see the plan or policy document oneRequires pre-approval. Limited to 120days in-network and 60 out-of-networkfacility days for a combined maximumof 120 days per calendar year. There is aseparate 600 deductible per inpatientstay for out-of-network facilities.4 of 9

CommonMedical EventServices You May NeedHospice servicesIf your child needsdental or eye careWhat You Will PayLimitations, Exceptions, & OtherNetwork ProviderOut-of-NetworkImportant Information(You will pay theProvider(You will payleast)the most)20% Coinsurance.Requires pre-approval. There is a40% Coinsurance.separate 600 deductible per inpatientstay for out-of-network facilities.Children’s eye exam 35.00 Copayment per visit Not Covered.for Specialist. Deductibledoes not apply.Coverage is limited to 1 visit.Children’s glassesNot Covered.Not Covered.noneChildren’s dental check-upNot Covered.Not Covered.none* For more information about limitations and exceptions, see the plan or policy document athttp://www.nj.gov/treasury/pensions/index.shtml5 of 9

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excludedservices.) Cosmetic Surgery Long Term Care Routine foot care Dental care (Adult) Private-duty nursing Weight Loss ProgramsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture (for pain management only) Hearing Aids (Only covered for members age15 or younger) Bariatric surgery (requires pre-approval) Infertility treatment (requires pre-approval) Chiropractic care (limited to 30 visits/year) Non-emergency care when traveling outsidethe U.S. (Subject to deductible/coinsuranceand balance billing.)Routine eye care (Adult)Most coverage provided outside the UnitedStates. (Subject to deductible/coinsuranceand balance billing.)* For more information about limitations and exceptions, see the plan or policy document athttp://www.nj.gov/treasury/pensions/index.shtml6 of 9