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9 Trenton, NJ 08625-0299 3C. MEDICAL COVERAGE (Check one box only). HORIZON AETNA MEDICARE ADVANTAGE* NJ DIRECT15 Aetna PPO ESA**15 (Freedom15) 2. TYPE OF ACTIVITY Check one box in Section 2A; If you select Plan Change, complete Sections 2B; 3, 4, and 5; for Dependent/Coverage Level Change, complete Section 2B and 5; if you select Cancel Coverage, go to Sections 3 and 4. NJ DIRECT10 Plan Change Add/Delete Dependent Other Changes.

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