2023 AtlantiCare Benefits Booklet

Medical

Compare 2023 Plan Choices

TABLE OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 SERVICE CENTERS AND WEBSITES..........4 HOW TO ENROLL....5-6 MEDICAL..............7-14 PRESCRIPTION DRUG. ................15-17 ADDITIONAL MEDICAL PLAN RESOURCES........18-22 DENTAL...............23-24 VISION.....................25 LIFECENTER..............26 LIFE INSURANCE. .....27 DISABILITY...............28 VOLUNTARY OFFERINGS. ........29-32 SPENDING ACCOUNTS. ............33 RETIREMENT BENEFITS..................34 WELLNESS. .........35-38 LEGAL NOTICES...39-41 GLOSSARY..........42-43 FAQs...................44-46 CONTACTS.........47-48 FORMS................49-58

Horizon Engaged Plan

PPO Plan

Medical Services

Inner Circle

Tier 2

Inner Circle

Tier 2

Out-of-Network

Deductible (per person/per family)

$2,000/$4,000

$2,500/$5,000*

N/A

$1,000/$2,000

$2,000/$4,000

*Wellness credits can reduce deductible to $500/1,000

Out-of-Pocket Maximum after Deductible (per person/per family)

$7,350/$14,700

$7,350/$14,700

$9,200/$18,400

Facility Benefits

Covered 100% after deductible

Covered 100% after $1,500 copay/visit and deductible

Covered 100% after deductible

Covered 100% after $1,000 copay/visit

$2,000 copay/visit then covered 50%; no deductible

Room & Board / Ancillary

Outpatient Facility Benefits

Covered 100% after $25 copay and deductible Covered 100% after $25 copay and deductible Covered 100% after deductible Covered 100% after deductible Covered 100% after deductible

Outpatient Surgery (Hospital Based)

Covered 70% after $1,250 copay/visit and deductible

Covered 100% after $25 copay

Covered 100% after $1,000 copay/visit

$2,000 copay/visit then covered 50%; no deductible

Outpatient Surgery (Surgical Center)

Covered 70% after $1,000 copay/visit and deductible

Covered 100% after $25 copay

Covered 100% after $700 copay/visit

Covered 50% after deductible

Physician Services

Covered 70% after deductible Covered 70% after deductible Covered 70% after deductible Covered 100% after $50 copay/visit; all other services rendered in the office covered 70% after deductible Covered 100% after $65 copay/visit; all other services rendered in the office covered 70% after deductible

Covered 50% after deductible Covered 50% after deductible Covered 50% after deductible

Surgeon

Covered 70% after deductible

Covered 100%

Anesthesia

Covered 70% after deductible

Covered 100%

Inpatient Physician Visit

Covered 70% after deductible

Covered 100%

Covered 100% after $50 copay/visit and wellness deductible; all other services rendered in the office covered 70% after deductible

Covered 100% after $10 copay and deductible

Physician Office Visits - Primary Care

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 100% after $65 copay/visit and wellness deductible; all other services rendered in the office covered 70% after deductible

Covered 100% after $10 copay and deductible

Physician Office Visits - Specialist

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 50% after deductible

Physician Office Visits - Routine Well Care

Covered 100%

Covered 100%

Covered 100% Covered 100%

This chart is meant as an overview only. For detailed information, please refer to the Summary Plan Description posted under “Benefit Information” on the HR Portal: Benefits Tab. * For Engaged Plan only, the deductible can be reduced through wellness credits. ** AtlantiCare also covers some services for gender assignment. Check the plan document for more information.

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