ENROLLMENT APPLICATIONS

ACTIVE EMPLOYEES — NJ DIRECT, Aetna, and Cigna Plans

• Health Benefits Program Applications
  — State Employees Adobe PDF (54K)
  — Local Government Employees Adobe PDF (55K)
  — Local Education Employees Adobe PDF (52K)
  
  — Part-time Employees Adobe PDF (43K)
  — Intermittent State Employees Adobe PDF (41K)
  
  Applications must be certified by your employer before submitting to the Division of Pensions and Benefits

• Application for Chapter 375 Coverage Over age children up to age 31 Adobe PDF (90K)

ACTIVE EMPLOYEES — DENTAL PLANS

• Employee Dental Plans Application Adobe PDF (46K)
  for State Employees and participating Local Government/Local Board of Education Employees
  (RETIREES USE RETIRED COVERAGE ENROLLMENT APPLICATION)

RETIREES — NJ DIRECT, Aetna, Cigna, and Dental Plans

• Retired Coverage Enrollment Application Adobe PDF (39K)
  This application is for new retiree enrolment only.
  
  
• Retired Change of Status Application Adobe PDF (39K)
  This application is for enrolled retirees who are changing plans or coverage levels.
  
  
• SHBP Retiree Wellness Program Information
  For State retirees who attained 25 years of service after June 30, 2007 and before June 28, 2011.
  
  
• Wellness Program Letter and Pledge Form Adobe PDF (54K)
  
  
• NJ DIRECT Retiree Wellness Brochure Adobe PDF (505K)
  
• NJ DIRECT Annual Wellness Certification Adobe PDF (96K)
  
  
• Cigna Annual Wellness Certification Adobe PDF (96K)

WAIVER FORM

• Waiver Form for State Employees or Local Employees Adobe PDF (20K)

CLAIM FORMS

SHBP and SEHBP MEDICAL PLANS

• NJ DIRECT Claim Form for Out-of-Network claims Adobe PDF (204K)
  
  
• For Aetna and Cigna plan claims, contact the plans directly

EMPLOYEE PRESCRIPTION PLANS

Medco Order and Claim Forms
For orders and claims beginning January 1, 2010

• Medco Mail-Order Form Adobe PDF (95K)
  
  
• Medco Prescription Drug Reimbursement Form Adobe PDF (112K)

DENTAL PLANS

• Employee Dental Expense Plan (Aetna) Claim Form Adobe PDF (149K)
  
  
• Retiree Dental Expense Plan (Aetna) Claim Form Adobe PDF (149K)