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
DEDUCTIBLES (INDIVIDUAL) $100 per calendar year None $100 per calendar year ; $200 per hospital admission None None None None None DEDUCTIBLES (INDIVIDUAL)
DEDUCTIBLES (FAMILY MAXIMUM) Employee and/or retiree plus one dependent must meet individual deductible None $250 per calendar year;
$200 per hospital admission
None None None None None DEDUCTIBLES (FAMILY MAXIMUM)
MAXIMUM OUT-OF-POCKET (INDIVIDUAL) $400 per calendar year coinsurance + $100 deductible $400 per calendar year (coinsurance only) $2,000 per calendar year (coinsurance only) No maximum $1,500 per calendar year (sum of copayments) No maximum $650 per calendar year (sum of copayments) $2,700 per calendar year (sum of copayments) MAXIMUM OUT-OF-POCKET (INDIVIDUAL)
MAXIMUM OUT-OF-POCKET (FAMILY) $400 X number of dependents + deductibles $1,000 per calendar year (coinsurance only) $5,000 per calendar year (coinsurance only) No maximum $3,000 per calendar year (sum of copayments), then 100% No maximum $650 per person per calendar year (sum of copayments), then 100% $5,400 per calendar year (sum of copayments), then 100% MAXIMUM OUT-OF-POCKET (FAMILY)
MAXIMUM PLAN COVERED EXPENSES
ANNUAL/LIFETIME
$1,000,000 lifetime (major medical expense only); $10,000 annual mental health - $20,000 lifetime mental health; up to $2,000 restoration feature each year3
  • Unlimited;
  • $15,000 annual mental health;
  • $50,000 lifetime mental health;
  • up to $2,000 restoration feature each year3
  • $1,000,000 lifetime;
  • $15,000 annual mental health;
  • $50,000 lifetime mental health;
  • up to $2,000 restoration feature each year3
Unlimited Unlimited Unlimited Unlimited Unlimited MAXIMUM PLAN COVERED EXPENSES
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.


3Biologically-based mental health conditions are treated like any other illness and not subject to annual or lifetime mental health dollar maximums or separate mental health visit limits.

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