ENROLLMENT APPLICATIONS

ACTIVE EMPLOYEES — Aetna and Horizon/NJ DIRECT Plans - for Plan Year 2013

• State Employee Applications
  — PPO and HMO Plans Adobe PDF (54K)
  — High Deductible Health Plans Adobe PDF (54K)
       and HSA Contribution Forms for Centralized Payroll | Other State Employees Adobe PDF (23K)
  
  State Part-Time Employees
  — PPO and HMO Plans Adobe PDF (43K)
  — High Deductible Health Plans Adobe PDF (45K)
       and HSA Contribution Forms for Centralized Payroll | Other State Employees Adobe PDF (23K)
  
  State Intermittent Employees
  — PPO and HMO Plans Adobe PDF (41K)
  — Hign Deductible Health Plans Adobe PDF (45K)
       and HSA Contribution Forms for Centralized Payroll Adobe PDF (23K)
  
  
• Local Government Employee Aplications
  — Application for PPO and HMO Plans Adobe PDF (54K)
  — Application for High Deductible Health Plans Adobe PDF (54K)
      and HSA Contribution Form Adobe PDF (23K)
  
  
• Local Education Employee Applications
  — Application for PPO and HMO Plans Adobe PDF (52K)
  — Application for High Deductible Health Plans Adobe PDF (54K)
       and HSA Contribution Form Adobe PDF (23K)
  
  Education Part-Time Employees
  — PPO and HMO Plans Adobe PDF (43K)
  — High Deductible Health Plans Adobe PDF (45K)
       and HSA Contribution Form Adobe PDF (23K)
  
  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 — Aetna, Horizon/NJ DIRECT, and Dental Plans - for Plan Year 2013

• Retired Coverage Enrollment Application — New retiree enrollments ONLY.
  — PPO and HMO Plans Adobe PDF (39K)
  — High Deductible Health Plans Adobe PDF (35K)
  
  
• Retired Change of Status Application — Enrolled retirees who are changing plans or coverage levels.
  — PPO and HMO Plans Adobe PDF (39K)
  — High Deductible Health Plans Adobe PDF (36K)
  
  
• 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)
  
  
• For Aetna Wellness information and forms visit: aetnastatenj.com/wellness.php

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)
  
  
• Aetna plan claims, contact Aetna directly

EMPLOYEE PRESCRIPTION PLANS

Express Scripts/Medco Order and Claim Forms

• Express Scripts/Medco Mail-Order Form Adobe PDF (95K)
  
  
• Express Scripts/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)

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