2024 Benefits Booklet

Medical

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

Compare 2024 Plan Choices

Horizon Engaged Plan

PPO Plan

Medical Services

Inner Circle

Tier 2

Inner Circle

Tier 2

Out-of-Network

Supplemental Services

Covered 100% after $5 copay/visit

Covered 100% after $20 copay/visit

Covered 100% after $5 copay/visit

Covered 100% after $20 copay/visit Covered 100% after $50 copay/visit and deductible; all other services rendered in the office covered 70% after deductible Covered 100% after $150 copay Office and freestanding clinic: Covered 100% after $50 copay/visit and deductible Facility: Covered 70% after deductible Office and freestanding clinic: Covered at 70% after deductible for services performed at a freestanding facility or in an Office Facility: Covered 70% after deductible

Covered 100% after $20 copay/visit

Telemedicine

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

Covered 100% after $20 copay and deductible

Covered 100% after $20 copay and deductible

Urgent Care

Covered 100% after $60 copay

Covered 100% after $150 copay and deductible

Covered 100% after $150 copay and deductible

Covered 100% after $150 copay

Emergency Services

Covered 100% after $150 copay

Office and freestanding clinic: Covered 100% after $50 copay/visit and deductible

Covered 100% after $10 copay and deductible

Covered 100% after $10 copay/visit

Covered 50% after deductible

Diagnostic X-ray

Facility: Covered 70% after deductible

Covered at 70% after deductible for services performed at a freestanding facility or in an Office Facility: Covered 70% after deductible

Diagnostic hi-tech imaging

Covered 100% after $10 copay and deductible

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 100% after $10 copay/visit and deductible

Covered 100% after $50 copay/visit and deductible

Covered 100% after $10 copay/visit

Covered 70% after deductible

Covered 50% after deductible

DiagnosticTests

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. Vision care expense benefit for all plans (no network limitations) Routine Vision Exam annually $70 Eyeglasses and/or Contact Lenses every two years $60 Must submit a claim form for reimbursement.

To learn more about your Wellness Benefits scan here:

*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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