FH-0278-0809x
GREEN
GREEN
FOR EMPLOYERS WHO OFFER THE EMPLOYEE PRESCRIPTION DRUG PLAN OR A PRIVATE PLAN
DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY SCHOOL EMPLOYEES' HEALTH BENEFITS PROGRAM
LOCAL MONTHLY ACTIVE GROUP - EDUCATION EMPLOYERS
RATES EFFECTIVE 1/1/2010 to 12/31/2010
PLAN/COVERAGE
DESCRIPTION
EMPLOYER
SINGLE COST
DEPENDENT
COST
TOTAL
$438.55
$440.13
$440.70
$439.24
------$546.58
$655.65
$174.71
$438.55
$986.71
$1,096.35
$613.95
$460.67
$462.25
$462.82
$461.36
------$574.24
$688.85
$183.55
$460.67
$1,036.49
$1,151.67
$644.91
$435.16
$436.74
$437.31
$435.85
------$542.38
$650.61
$173.38
$435.16
$979.12
$1,087.92
$609.23
$439.51
$441.09
$441.66
$440.20
------$547.82
$657.12
$175.12
$439.51
$988.91
$1,098.78
$615.32
$130.00
$130.00
$130.00
$130.00
------$162.50
$195.00
$52.00
$130.00
$292.50
$325.00
$182.00
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-0279-0809x
PINK
PINK
FOR EMPLOYERS WHO OFFER PRESCRIPTION DRUGS THROUGH THE SEHBP
BASED ON THE MEDICAL PLAN IN WHICH THE SUBSCRIBER IS ENROLLED.
DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY SCHOOL EMPLOYEES' HEALTH BENEFITS PROGRAM
LOCAL MONTHLY ACTIVE GROUP - EDUCATION EMPLOYERS
RATES EFFECTIVE 1/1/2010 to 12/31/2010
PLAN/COVERAGE
DESCRIPTION
EMPLOYER
SINGLE COST
NJ DIRECT15 - #150 WITH PRESCRIPTION DRUG #211
DEPENDENT
COST
TOTAL
$526.25
$527.83
$528.40
$526.94
------$656.22
$787.21
$209.80
$526.25
$1,184.05
$1,315.61
$736.74
$552.80
$554.38
$554.95
$553.49
------$689.40
$827.04
$220.42
$552.80
$1,243.78
$1,381.99
$773.91
$552.66
$554.24
$554.81
$553.35
------$689.25
$826.85
$220.37
$552.66
$1,243.49
$1,381.66
$773.72
------$696.17
$835.14
$222.59
$558.18
$1,255.93
$1,395.47
$781.46
1
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
$558.18
$559.76
$560.33
$558.87
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