FH-0276-0809X
BLUE
BLUE
FOR EMPLOYERS WHO OFFER THE EMPLOYEE PRESCRIPTION DRUG PLAN OR A PRIVATE DRUG PLAN
DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE HEALTH BENEFITS PROGRAM
LOCAL MONTHLY ACTIVE GROUP - LOCAL GOVERNMENT EMPLOYERS
RATES EFFECTIVE 1/1/2010 to 12/31/2010
PLAN/COVERAGE
DESCRIPTION
EMPLOYER
SINGLE COST
DEPENDENT
COST
TOTAL
$470.45
$472.03
$472.60
$471.14
------$586.47
$703.51
$187.48
$470.45
$1,058.50
$1,176.11
$658.62
$494.02
$495.60
$496.17
$494.71
------$615.95
$738.88
$196.92
$494.02
$1,111.55
$1,235.05
$691.63
$474.25
$475.83
$476.40
$474.94
------$591.25
$709.24
$189.02
$474.25
$1,067.08
$1,185.64
$663.96
$479.00
$480.58
$481.15
$479.69
------$597.17
$716.34
$190.91
$479.00
$1,077.75
$1,197.49
$670.60
$139.52
$139.52
$139.52
$139.52
------$174.39
$209.26
$55.79
$139.52
$313.91
$348.78
$195.31
NJ DIRECT15 - #150
Single
Member & Spouse/Partner
Family
Parent & Child
NJ DIRECT10 - #050
Single
Member & Spouse/Partner
Family
Parent & Child
AETNA, INC. - #019
Single
Member & Spouse/Partner
Family
Parent & Child
CIGNA HEALTHCARE HMO - #020
Single
Member & Spouse/Partner
Family
Parent & Child
PRESCRIPTION DRUG PROGRAM - #201
Single
Member & Spouse/Partner
Family
Parent & Child
FH-0277-0809x
YELLOW
YELLOW
FOR EMPLOYERS WHO OFFER PRESCRIPTION DRUGS THROUGH THE SHBP
BASED ON THE MEDICAL PLAN IN WHICH THE SUBSCRIBER IS ENROLLED.
DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE HEALTH BENEFITS PROGRAM
LOCAL MONTHLY ACTIVE GROUP - LOCAL GOVERNMENT EMPLOYERS
RATES EFFECTIVE 1/1/2010 to 12/31/2010
PLAN/COVERAGE
DESCRIPTION
EMPLOYER
SINGLE COST
DEPENDENT
COST
TOTAL
$564.53
$566.11
$566.68
$565.22
------$704.08
$844.64
$225.13
$564.53
$1,270.19
$1,411.32
$790.35
$592.83
$594.41
$594.98
$593.52
------$739.44
$887.08
$236.43
$592.83
$1,333.85
$1,482.06
$829.95
$602.30
$603.88
$604.45
$602.99
------$751.32
$901.32
$240.24
$602.30
$1,355.20
$1,505.77
$843.23
------$758.83
$910.34
$242.65
$608.33
$1,368.74
$1,520.82
$851.67
NJ DIRECT15 - #150 WITH PRESCRIPTION DRUG #2111
Single
Member & Spouse/Partner
Family
Parent & Child
NJ DIRECT10 - #050 WITH PRESCRIPTION DRUG #2101
Single
Member & Spouse/Partner
Family
Parent & Child
AETNA, INC. - #019 WITH PRESCRIPTION DRUG #2122
Single
Member & Spouse/Partner
Family
Parent & Child
CIGNA HEALTHCARE HMO - #020 WITH PRESCRIPTION DRUG #2132
Single
Member & Spouse/Partner
Family
Parent & Child
$608.33
$609.91
$610.48
$609.02
1
Subscribers in NJ DIRECT10 and NJ DIRECT15 are provided a drug reimbursement plan administered by Medco.
2
Subscribers in Aetna HMO or CIGNA HealthCare HMO are provided a three tier copayment benefit administered by Medco.
NOTE: When enrolling for coverage, list the medical plan unit number; not the prescription plan number.
DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
DENTAL PLANS
LOCAL GOVERNMENT AND LOCAL EDUCATION EMPLOYERS
RATES EFFECTIVE 1/1/2010 to 12/31/2010
PLAN/COVERAGE
DESCRIPTION
DENTAL EXPENSE PLAN - #399
MONTHLY BILLING RATE
MAXIMUM EMPLOYEE
CONTRIBUTION (50%)
TOTAL MONTHLY
RATE
$21.08
$36.63
$59.94
$44.40
$42.17
$73.27
$119.88
$88.80
$12.59
$21.87
$35.79
$26.51
$25.18
$43.74
$71.58
$53.02
$12.01
$20.88
$34.16
$25.30
$24.02
$41.77
$68.32
$50.60
$10.79
$18.77
$30.70
$22.75
$21.59
$37.55
$61.41
$45.51
$10.26
$17.84
$29.19
$21.62
$20.53
$35.68
$58.38
$43.24
$9.78
$17.00
$27.81
$20.60
$19.57
$34.00
$55.63
$41.21
$10.46
$18.21
$29.79
$22.07
$20.93
$36.43
$59.58
$44.15
Single
Member & Spouse/Partner
Family
Parent & Child
DENTAL PROVIDER ORGANIZATIONS (DPO)
BENECARE - #301
Single
Member & Spouse/Partner
Family
Parent & Child
COMMUNITY DENTAL - #302
Single
Member & Spouse/Partner
Family
Parent & Child
CIGNA DHMO - #305
Single
Member & Spouse/Partner
Family
Parent & Child
HEALTHPLEX - #307
Single
Member & Spouse/Partner
Family
Parent & Child
HORIZON DENTAL CHOICE - #317
Single
Member & Spouse/Partner
Family
Parent & Child
AETNA DMO - #319
Single
Member & Spouse/Partner
Family
Parent & Child