oopc0105.htm

Note: SHBP Plans for State Employees Covered Under New Labor Agreements Effective July 2007

PLAN & TELEPHONE #	#102 TRADITIONAL¹ 1-800-414-7427 www.horizonblue.com/shbp	#004 - NJ PLUS www.horizonblue.com/shbp		#005 AETNA HMO 1-800-309-2386 www.aetna.com	#006 CIGNA HEALTHCARE HMO 1-800-244-6224 www.cigna.com/health	#007 OXFORD HMO 1-800-760-4566 www.oxfordhealth.com	#008 AMERIHEALTH HMO 1-800-877-9829 www.amerihealth.com	#009 HEALTH NET⁶ HMO 1-800-441-5741 www.healthnet.com	PLAN & TELEPHONE #
PLAN & TELEPHONE #	#102 TRADITIONAL¹ 1-800-414-7427 www.horizonblue.com/shbp	In-network 1-800-414-7427	Out-of-network¹ 1-800- 414-7427	#005 AETNA HMO 1-800-309-2386 www.aetna.com		#007 OXFORD HMO 1-800-760-4566 www.oxfordhealth.com	#008 AMERIHEALTH HMO 1-800-877-9829 www.amerihealth.com	#009 HEALTH NET⁶ HMO 1-800-441-5741 www.healthnet.com	PLAN & TELEPHONE #
SERVICE AREA	Unrestricted	All of NJ and FL; Parts of DE, NY, and PA	Unrestricted	All of NJ, CT, DE, ME, and Wash.DC; Parts of AZ, FL, GA, IL, IN, MA, MD, NC, NH, NV, NY, OH, PA, TN, TX, VA, and WA	All of NJ, AZ, CT, DE, MD, ME, NH, NM, RI, VT & Wash. DC; Parts of AL, AR, CA, CO, FL, GA, ID, IL, IN, KS, KY, LA, MA, MI, MO, MS, NV, NY, NC, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI & 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)	$250 per calendar year	None	$100 per calendar year; $200 per hospital admission	None	None	None	None	None	DEDUCTIBLES (INDIVIDUAL)
DEDUCTIBLES (FAMILY MAXIMUM)	Employee $250 per year, plus $250 for all other dependents in aggregate. Maximum - $500 per family	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 plus $250 deductible	$400 per calendar year (coinsurance only)	$2,000 per calendar year (coinsurance only)	No maximum	$1,500 per calendar year (sum of copayments); then 100%	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 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 year with a lifetime maximum of $20,000³	Unlimited; $15,000 annual mental health; $50,000 lifetime mental health; up to $2,000 restoration feature each year with a lifetime maximum of $50,000³	$1,000,000 lifetime (major medical expense only); $15,000 annual mental health; $50,000 lifetime mental health; up to $2,000 restoration feature each year with a lifetime maximum of $50,000³	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. 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.