FH-0278-0810X
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 1/1/2011 to 12/31/2011
PLAN/COVERAGE
DESCRIPTION
EMPLOYER
SINGLE COST
DEPENDENT
COST
TOTAL
$475.83
$477.50
$478.11
$476.56
------$593.08
$711.43
$189.58
$475.83
$1,070.58
$1,189.54
$666.14
$499.83
$501.50
$502.11
$500.56
------$623.09
$747.45
$199.17
$499.83
$1,124.59
$1,249.56
$699.73
$487.38
$489.05
$489.66
$488.11
------$607.56
$728.81
$194.23
$487.38
$1,096.61
$1,218.47
$682.34
$490.05
$491.72
$492.33
$490.78
------$610.91
$732.81
$195.30
$490.05
$1,102.63
$1,225.14
$686.08
$135.20
$135.20
$135.20
$135.20
------$169.00
$202.80
$54.08
$135.20
$304.20
$338.00
$189.28
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-0279-0810X
PINK
PINK
FOR EMPLOYERS WHO OFFER PRESCRIPTION DRUGS THROUGH THE SHBP BASED ON THE MEDICAL
PLAN 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 1/1/2011 to 12/31/2011
PLAN/COVERAGE
DESCRIPTION
EMPLOYER
SINGLE COST
NJ DIRECT15 - #150 WITH PRESCRIPTION DRUG #211
Single
Member & Spouse/Partner
Family
Parent & Child
DEPENDENT
COST
TOTAL
------$712.04
$854.18
$227.65
$570.98
$1,284.69
$1,427.44
$799.36
------$748.04
$897.39
$239.17
$599.79
$1,349.50
$1,499.46
$839.69
------$772.06
$926.20
$246.86
$618.98
$1,392.71
$1,547.46
$866.57
------$776.32
$931.30
$248.23
$622.37
$1,400.36
$1,555.95
$871.33
1
$570.98
$572.65
$573.26
$571.71
NJ DIRECT10 - #050 WITH PRESCRIPTION DRUG #2101
Single
Member & Spouse/Partner
Family
Parent & Child
$599.79
$601.46
$602.07
$600.52
AETNA, INC. - #019 WITH PRESCRIPTION DRUG #2122
Single
Member & Spouse/Partner
Family
Parent & Child
$618.98
$620.65
$621.26
$619.71
CIGNA HealthCare HMO - #020 WITH PRESCRIPTION DRUG #213
Single
Member & Spouse/Partner
Family
Parent & Child
$622.37
$624.04
$624.65
$623.10
2
1
Subscribers in NJ DIRECT10 and NJ DIRECT15 are provided 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.
DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE DENTAL PROGRAM
LOCAL MONTHLY ACTIVE GROUP
LOCAL GOVERNMENT AND EDUCATION EMPLOYERS
RATES EFFECTIVE 1/1/2011 to 12/31/2011
DESCRIPTION
OF COVERAGE
DENTAL EXPENSE PLAN - #399
Single
Member & Spouse/Partner
Family
Parent & Child
MONTHLY BILLING RATE
MAXIMUM EMPLOYEE
CONTRIBUTION (50%)
TOTAL MONTHLY
RATE
$21.50
$37.37
$61.14
$45.29
$43.01
$74.74
$122.28
$90.58
$12.71
$22.09
$36.15
$26.77
$25.43
$44.18
$72.30
$53.55
$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
$9.75
$16.95
$27.73
$20.54
$19.50
$33.90
$55.46
$41.08
$9.98
$17.34
$28.37
$21.01
$19.96
$34.68
$56.74
$42.03
$10.46
$18.21
$29.79
$22.07
$20.93
$36.43
$59.58
$44.15
DENTAL PROVIDER ORGANIZATIONS (DPO)
BENECARE (DPO #301)
Single
Member & Spouse/Partner
Family
Parent & Child
COMMUNITY DENTAL (DPO #302)
Single
Member & Spouse/Partner
Family
Parent & Child
CIGNA (DPO #305)
Single
Member & Spouse/Partner
Family
Parent & Child
HEALTHPLEX (DPO #307)
Single
Member & Spouse/Partner
Family
Parent & Child
HORIZON DENTAL CHOICE (DPO #317)
Single
Member & Spouse/Partner
Family
Parent & Child
AETNA DMO (DPO #319)
Single
Member & Spouse/Partner
Family
Parent & Child