DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE HEALTH BENEFITS PROGRAM
CHAPTER  172, P.L. 2003
PART-TIME ACTIVE EMPLOYEE GROUP RATES
EFFECTIVE 1/1/2004 TO 12/31/2004

PLAN NAME AND
COVERAGE DESCRIPTION

PART-TIME EMPLOYEE
MONTHLY RATE

NJ  PLUS - #001

Single

$314.85

Member & Spouse

$686.27

Family

$816.83

Parent & Child(ren)

$473.67

PRESCRIPTION DRUG PROGRAM - #201

Single

$113.09

Member & Spouse

$258.49

Family

$271.50

Parent & Child(ren)

$150.94

DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE HEALTH BENEFITS PROGRAM
CHAPTER  172, P.L. 2003
PART-TIME STATE RETIREE GROUP RATES
EFFECTIVE 1/1/2004 TO 12/31/2004

PLAN NAME AND
COVERAGE DESCRIPTION

PART-TIME STATE RETIREE
MONTHLY RATE

NJ  PLUS - #001 *

Single - No Medicare

$570.07

Single - On Medicare

$370.01

Member & Spouse - No Medicare

$1,242.54

Member & Spouse - One on Medicare

$940.08

Member & Spouse - Both on Medicare

$739.93

Family - No Medicare

$1,478.97

Family - One on Medicare

$1,176.43

Family - Both on Medicare

$976.31

Parent & Child(ren) - No Medicare

$857.62

Parent & Child(ren) - Retiree on Medicare

$606.36

"One on Medicare" means either a member or a spouse but not both on Medicare.

*Retired Group NJ PLUS coverage includes prescription drug benefits.

DEPARTMENT OF THE TREASURY-DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE HEALTH BENEFITS PROGRAM
CHAPTER  172, P.L. 2003
PART-TIME LOCAL EDUCATION RETIREE GROUP RATES
EFFECTIVE 1/1/2004 TO 12/31/2004

PLAN NAME AND
COVERAGE DESCRIPTION

PART-TIME
LOCAL EDUCATION RETIREE MONTHLY RATE

NJ  PLUS - #001 *

Single - No Medicare

$521.73

Single - On Medicare

$350.29

Member & Spouse - No Medicare

$1,161.33

Member & Spouse - One on Medicare

$872.06

Member & Spouse - Both on Medicare

$700.60

Family - No Medicare

$1,351.17

Family - One on Medicare

$1,061.86

Family - Both on Medicare

$890.46

Parent & Child(ren) - No Medicare

$770.42

Parent & Child(ren) - Retiree on Medicare

$540.14

"One on Medicare" means either a member or a spouse but not both on Medicare.

*Retired Group NJ PLUS coverage includes prescription drug benefits.

DEPARTMENT OF THE TREASURY - DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE HEALTH BENEFITS PROGRAM
CHAPTER  172, P.L. 2003
PART-TIME COBRA GROUP RATES
EFFECTIVE 1/1/2004 TO 12/31/2004

PLAN NAME AND
COVERAGE DESCRIPTION

PART-TIME COBRA
MONTHLY RATE

NJ  PLUS - #001

Single

$321.15

Member & Spouse

$699.99

Family

$833.16

Parent & Child(ren)

$483.14

PRESCRIPTION DRUG PROGRAM - #201

Single

$115.35

Member & Spouse

$263.65

Family

$276.93

Parent & Child(ren)

$153.96