PLAN
&
TELEPHONE #
#002 TRADITIONAL1
1-800-414-7427
www.horizonblue.com
#001 - NJ PLUS
www.horizonblue.com
#019
AETNA HMO
1-800-309-2386
www.aetna.com
#020
CIGNA HEALTHCARE HMO
1-800-244-6224
www.cigna.com/health
#028
OXFORD HMO
1-800-760-4566
www.oxfordhealth.com
#033
AMERIHEALTH HMO
1-800-877-9829
www.amerihealth.com
#034
HEALTH NET6 HMO
1-800-441-5741
www.healthnet.com
PLAN
&
TELEPHONE #
In-network
1-800-414-7427
Out-of-network1
1-800-414-7427
SERVICE AREA Unrestricted All of NJ and FL;
Parts of NY and PA
Unrestricted All of NJ, CT, DE, ME, and Wash.DC; Parts of AZ, FL, IL, IN, MA, MD, NC, NH, NV, NY, OH, PA, TX, and VA All of NJ, AZ, CT, DE, SC and Washington DC; Parts of CA, FL, GA, MD, NC, NY, PA, VA, and WV, All of NJ; parts of NY All of NJ and DE; parts of PA All of NJ and CT; Parts of NY SERVICE AREA
RADIATION/CHEMOTHERAPY
OUTPATIENT
80% after deductible
100%
70% after deductible
100% after $5 copayment per office visit
100% after $5 copayment per office visit
100% after $5 copayment per office visit
100% after $5 copayment per office visit
100% after $5 copayment per office visit
RADIATION/CHEMOTHERAPY
OUTPATIENT
HOSPICE
100%
100%
70% after deductible
100%
100%
100%
100%
100%
HOSPICE
PHYSICAL/SPEECH THERAPY4
80% after deductible
100% after $5 copayment per visit
70% after deductible
100% after $5 copayment per visit for up to 60 visits per condition per year
100% after $5 copayment per visit for up to 60 visits per condition per year
100% after $5 copayment per visit for up to 60 visits per condition per year
100% after $5 copayment per visit for up to 60 visits per condition per year
100% after $5 copayment per visit for up to 60 visits per condition per year
PHYSICAL/SPEECH THERAPY2
DENTAL COVERAGE The SHBP Employee Dental Plans are offered to active employees whose employers have elected to offer these plans as a separate dental benefit. These plans fall under one of two basic types: the Dental Expense Plan, and several
Dental Plan Organizations (DPOs). Retirees who enroll in the SHBP may choose to join the Retiree Dental Expense Plan. For more information about the dental plans, see the SHBP Employee Dental Plans Member Handbook or
Retiree Dental Expense Plan Member Handbook which are available from your employer, from the Division of Pensions and Benefits, or at the SHBP home page at: www.state.nj.us/treasury/pensions/shbp.htm
DENTAL COVERAGE
LAB TESTS
80% after deductible; some charges paid at 100%
100%
70% after deductible
100%
100%
100%
100%
100%
X-RAYS/LAB TESTS
PRESCRIPTION DRUGS7,8,

Benefits for ACTIVE employees without employer prescription drug plan
80% after deductible
90% reimbursement
70% after deductible
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$10
Other brands
$20
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25

PRESCRIPTION DRUGS7,8,

Benefits for ACTIVE employees without employer prescription drug plan

PRESCRIPTION DRUGS8
RETIREES
Pharmacy
Copay9
30-day supply
Generic
$8
Preferred brand
$16
Other brands
$33

Mail Order
Copay9
90-day supply
Generic
$8
Preferred brand
$25
Other brands
$41
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$10
Other brands
$20
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25
Pharmacy
Copay
30-day supply
Generic
$5
Preferred brand
$10
Other brands
$20

Mail Order
Copay
90-day supply
Generic
$5
Preferred brand
$15
Other brands
$25
PRESCRIPTION DRUGS8
RETIREES
ROUTINE VISION EXAM
(Must Use In-Network Provider)

None

100% after $5 copayment; one exam per calendar year, no referral needed

None

100% after $5 copayment; exam every 1 to 3 years based on age; no referral needed

100% after $5 copayment; one exam per calendar year; no referral required

$50 reimbursed toward routine exam per 12 month period

100% after $5 copayment; one exam every 24 month period; must use specified vendor, no referral needed

100% after $5 copayment; one exam per calendar year, no referral needed

ROUTINE VISION EXAM
1Benefits, excluding hospital expenses, are based on the Horizon's discounted provider network allowance or the "reasonable and customary" fee schedule at the 90% percentile. Some State employees may not be eligible for
enrollment in the Traditional Plan; see other side of chart for details.


4Speech therapy limited to: restoration after a loss or impairment of a demonstrated previous ability to speak; develop or improve speech after surgical correction of a birth defect.

6Referral is not required from a PCP to a participating specialist.


7If your employer provides a separate prescription drug plan to employees, the medical plan will not include any drug coverage. If no separate prescription drug plan is provided, the medical plan will provide drug coverage as noted.

8Certain prescription drugs may require precertificatio prior to purchase. Please contact your health plan for details.


9The maximum out-of-pocket for prescription drug copayments per member is $1,000 per year. Once a person has paid $1,000 in copayments in the calendar year, that person is no longer required to pay any prescription drug copayments for the remainder of the calendar year.