2024 Benefits Booklet

Medical

Compare 2024 Plan Choices

TABLE OF CONTENTS WELCOME..............................2 WHAT’S NEW........................3 HOW TO ENROLL......... 4-5 MEDICAL......................... 6-13 PRESCRIPTION DRUG.............................. 14-15 ADDITIONAL MEDICAL PLAN RESOURCES............... 16-18 DENTAL......................... 19-20 VISION....................................21 LIFECENTER........................22 LIFE INSURANCE.............23 DISABILITY..........................24 VOLUNTARY OFFERINGS................. 25-28 SPENDING ACCOUNTS.........................29 RETIREMENT BENEFITS..............................30 CONTACTS.................. 31-32

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)

$7,700/$15,400

$7,700/$15,400

$7,750/$19,100

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

Room& Board / Ancillary

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

Outpatient Facility Benefits

Outpatient Surgery (Hospital Based) Outpatient Surgery (Surgical Center)

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

Covered 70% after $1,250 copay/visit and deductible Covered 70% after $1,000 copay/visit and deductible

Covered 100% after $25 copay Covered 100% after $25 copay

Covered 100% after $1,000 copay/visit

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

Covered 100% after $700 copay/visit

Covered 50% after deductible

Physician Services

Covered 100% after deductible Covered 100% after deductible Covered 100% after deductible

Covered 70% after deductible Covered 70% after deductible 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 PhysicianVisit

Covered 70% after deductible

Covered 100%

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

Physician OfficeVisits - Primary Care

Covered 100% after $10 copay and deductible

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

Physician OfficeVisits - Specialist

Covered 100% after $10 copay and deductible

Covered 100% after $10 copay/visit

Covered 50% after deductible

To learn more about your Wellness Benefits scan here:

Covered 50% after deductible

Physician OfficeVisits - RoutineWell 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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