NJ Division of Pensions and Benefits. Retiree State Health Benefits Plan (SHBP) Health Insurance (Medical and Prescription) Premium Sharing Schedule

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1 NJ Division of Pensions and Benefits Retiree State Health Benefits Plan (SHBP) Health Insurance (Medical and Prescription) Premium Sharing Schedule Employees who attained 25 or more years of service credit on or before July 1, 1997 No Premium Sharing (medical and prescription) Full reimbursement for standard cost of Medicare B premium (per eligible covered individual) provided by the State Employees who attained 25 or more years of service credit after July 1, 1997 and before June 30, 2007 No Premium Sharing for selective Retired Group State Health Benefits (i,e. Aetna Freedom/NJ Direct 15) Premium Sharing (Medical and Prescription) for NJ Direct 10 and Aetna Freedom 10 Partial reimbursement of $46.10 for Medicare B premium (per eligible covered individual) Employees who attained 25 years of service credit after June 30, 2007 and before June 28, 2011 Health Contribution is 1.5% of the retirement benefit* unless the retiree participates in SHBP Wellness Plan NJ Direct 10 and Aetna Freedom 10 are not available Partial reimbursement of $46.10 for Medicare Part B premium (per eligible covered individual) if hire date is prior to July 1, 1995 Employees who attained 20 or more years of service credit before June 28, 2011 and must still attain 25 years of service credit prior to retirement Health Contribution is 1,5% of the retirement benefit* NJ Direct 10 and Aetna Freedom 10 are not available Partial reimbursement of $46.10 for Medicare Part B premium (per eligible covered individual) if hire date is prior to July 1, 1995 Employees who attained 25 years of service credit on or after tune 28, 2011 Employee pays the Percentage of Premium for Retirees based on annual retirement benefit** o PERS -annual pension allowance o ABP - 50% of the last annual salary prior to retirement N1 Direct 10 and Aetna Freedom 10 are not available Partial reimbursement of $46.10 for Medicare Part B premium (per eligible covered individual) if hire date is prior to July 1, 1995 Employees who have not attained 25 or more years of service credit at retirement Pay the full cost of Retiree Health Premium No reimbursement of the Medicare B premium *ABP retirees pay an annual health contribution equal to 1.5% of 50% of the last annual salary prior to retirement. * *ABP/PERS retirees please refer to the Percentage of Premium for Retirees Chart. (https //www ni qov/treasury/pensions/documents/forms/hr1016,pdf) Retiree Health eligibility and premium sharing are determined by NJ State Law and the NJ Division of Pensions and Benefits and are subject to change. 7/2018

2 r T /,~eyour ee~ ~k~ ~ ~ N W ~ E State of New Jersey Department of the Treasury DIVISION OF PENSIONS &BENEFITS HEALTH BENEFITS ~ 1 ~ ~ ~, 1 1, ~ r ~ t Y~ f ~~ & "'Wi ~,` ~~ ~~. V ' d ~ ms's ~ } ~ ~ ~ ~ i.~~ Note: You must use the rate charts for retirees who pay the full cost of their coverage to first determine the full cost premium for the plan and coverage level you select. Then, use this chart to determine the percentage of the full cost for which you will be responsible. Annual Retirement Allowance Range Single Less than $20, % Member/Spouse/Partner or Parent/Child Family Less than $25, % 3% $20,000 - $24, % $25,000 - $29, % 4.5% 4% $30,000 - $34, % 6% 5% $35,000 - $39, % 7% 6% $40,000 - $44, % 8% 7 /a $45,000 - $49, % 10% 9% $50,000 - $54, % 15% 12% $55,000 - $59, % 17% 14% $60,000 - $64, % 21% 17% $65,000 - $69, % 23% 19% $70,000 - $74, % 26% 22% $75,000 - $79, % 27% 23% $80,000 - $84, % 24% $80,000 - $94, % $85,000 - $89, % $85,000 - $99, % $90,000 - $94, % $95,000 and over 35% $95,000 - $99, % $100,000 and over 35% $100,000 - $109, % $110,000 and over 35%

3 W N E N DPB Pensions &Benefits State Retired Group Medicare and Non-Medicare Monthly Rates Effective 1 /1 /2018 to 12/31 /2018 PLAN/COVERAGE DESCRIPTION MONTHLY RATES AETNA FREEDOMIO #018 (24B) PPO Plan with $10 Primary Care Copayment Single No Medicare $1, Single On Medicare $ Member &Spouse/Partner No Medicare $2, Member& Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $1,10227 Family No Medicare $3, Family One on Medicare $2, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $ NJ DIRECTIO #050(230) PPO Plan with $10 Primary Care Copayment Single No Medicare $1, Single On Medicare $ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $1, Family No Medicare $3, Family One on Medicare $2, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $$2~ 1 ~ AETNA FREEDOMIS #180(24C)- PPO Plan with $15 Primary Care Copayment Single No Medicare $1, Single On Medicare $549,32 Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $1, Family No Medicare $3, Family One on Medicare $2, $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $ NJ DIRECTI5 N150 (231) PPO Plan with $15 Primary Care Copayment Single No Medicare $1, Single On Medicare $ Member &Spouse/Partner No Medicare $2, Member& Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $1, Family No Medicare $3, Family One on Medicare $2, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $805.03

4 W N E NDPB s Pensions &Benefits State Retired Group Medicare and Non-Medicare Monthly Rates Effective 1 /1 /2018 to 12/31 /2018 PLAN/COVERAGE DESCRIPTION MONTHLY RATES AETNA HMO #019(232) HMO Plan with $10 Primary Care Copayment Single No Medicare $1, Single On Medicare $ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $1, Family No Medicare $2, Family One on Medicare $2, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $ HORIZON HMO #011 (246) HMO Plan with $10 Primary Care Copayment Single No Medicare $1, Single On Medicare $ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $1, Family No Medicare $ Family One on Medicare $2, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare ~922.3~ AETNA FREEDOM1525 #063(249) PPO Plan with $15 PrJmary Care /$25 Specialist Care Copayment Single No Medicare ~1 ~i 8$ 19 Single On Medicare Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare NJA Member &Spouse/Partner Both on Medicare Family No Medicare $2, Family One on Medicare Parent &Child No Medicare $1, Parent &Child Retiree on Medicare NJ DIRECT1525 #051 (234)- PPO Plan with $15 Primary Care / $25 Specialist Care Copayment Single No Medicare $1, Single On Medicare $ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $ Family No Medicare $2, Family One on Medicare $1, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $776.67

5 W N ENDPB s Pensions &Benefits State Retired Group Medicare and Non-Medicare Monthly Rates Effective 1 /1 /2018 to 12/31 /2018 PLAN/COVERAGE DESCRIPTION MONTHLY RATES AETNA HM01525 #061 (236) HMO Plan with $1B Primary Care / $25 Specialist Care Copayment Single No Medicare $1, Single On Medicare ~491.8~ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $ Family No Medicare $2, Family One on Medicare $1, $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $ HORIZON HM01525 #053(247) HMO Plan with $15 Primary Care /$25 Specialist Care Copayment Single No Medicare $1, Single One on Medicare $ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner Qne on Medicare $1, Member &Spouse/Partner Both on Medicare $1, Family No Medicare $2, Family One on Medicare $1, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $ AETNA FREEDOM2030 #064(24A) PPO Plan with $20 Primary Care /$30 Specialist Care Copayment Single No Medicare $1, Single One on Medicare Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare Member &Spouse/Partner Both on Medicare Family No Medicare $2~822.9~ Family One on Medicare Parent &Child No Medicare $1, Parent &Child Retiree on Medicare NJ DIRECT2030 #052(235) PPO Plan with $20 Primary Care /$30 Specialist Care Copayment Single No Medicare $1, Single One on Medicare $ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1, Member &Spouse/Partner Both on Medicare $ Family No Medicare $2,$22.97 Family One on Medicare $1, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $762.31

6 N W E N D P B State Retired Group Medicare and Non-Medicare Monthly Rates - Effective 1 /1/2018 to 12/31 /2018 pensions &Benefits PLAN/COVERAGE DESCRIPTION AETNA HM02030 #062 (237) HMO Plan with $20 Primary Care /$30 Specialist Care Copayment.MONTHLY RATES Single No Medicare $1, Single On Medicare Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare Member &Spouse/Partner Both on Medicare Family No Medicare $2, Family One on Medicare Parent &Child No Medicare $1, Parent &Child Retiree on Medicare HORIZON HM02030 #054 (248) HMO Plan with $20 Primary Care /$30 Specialist Care Copayment Single No Medicare $1, Single One on Medicare $ Member &Spouse/Partner No Medicare $2, Member &Spouse/Partner One on Medicare $1,59128 Member &Spouse/Partner Both on Medicare $1, Family No Medicare $2, Family One on Medicare $1, Family Both on Medicare $1, Parent &Child No Medicare $1, Parent &Child Retiree on Medicare $ AETNA VALUE HD4000 #092 (242) High Deductible Hea/fh Plan with $4,000 In-Network Deductible Single No Medicare $ Single On Medicare Member &Spouse/Partner No Medicare $1, Member &Spouse/Partner. One on Medicare Member &Spouse/Partner Both on Medicare Family No Medicare $1, Family One on Medicare Parent &Child No Medicare $ Parent &Child Retiree on Medicare NJ DIRECT HD4000 X1090 (240) High Deductible Health Plan with $4,000 In-Network Deductible Single No Medicare $ Single On Medicare Member &Spouse/Partner No Medicare $1, Member &Spouse/Partner One on Medicare Member &Spouse/Partner Both on Medicare Family No Medicare $1,629,49 Family One on Medicare Parent &Child No Medicare $ Parent &Child Retiree on Medicare 1)Subscribers are provided a prescription drug plan administered by OptumRx. 2) Horizon HMO service area for Plan #011, #053, and #054 is limited fo New Jersey, New Castle County, Delaware, and parts of Pennsylvania and New York. 3)The following plans are not available to Medicare-eligible retirees and retirees with Medicare-eligible dependents: AETNA FREEDOM2030 (#064); AETNA FREEDOM 1525 (#063); AETNA HM02030 (#062); and the HD plans (#090) and (#092).

7 Employees Who Attained 25 Years of Service Credit on or After June 28, 2011 Calculation Example ABP Retirees Jane Doe is retiring on July 1st. Her last annual base salary is $100,000 50% of salary = $50,000 Percentage of Premium for Retirees: 20% 2018 full cost of NJ Direct 15 with Prescription (single non- Medicare): $1, per month. 20% of $1, = $ per month 2018 Full Cost Rate Chart: htt~:// Percentage of Premium for Retirees Chart: ~df U niversity Human Resources

8 Employees Who Attained 25 Years of Service Credit on or After June 2S, 2011 Calculation Example PERS Retirees Jane Doe is retiring on July 1St. Her last annual base salary is $68, Annual Benefit = $34, Percentage of Premium for Retirees: 10% 2018 full cost of NJ Direct 15 with Prescription (single non- Medicare) : $1, per month. 10% of $1, = $ per month 2018 Full Cost Rate Chart: htt~:// Percentage of Premium for Retirees Chart: https ://w ww.n~~ov/treasury/pensions/documents/forms/hr 1016.~df U niversity Human Resources