2026 AtlantiCare Benefits Booklet

MEDICAL (CONT.)

Compare 2026 Medical Plan Choices

WELCOME....................................2 WHAT’S NEW..............................3 HOW TO ENROLL......................4 HEALTHCARE TRANSFORMATION CONSORTIUM (HTC)...............6 GETTING TO KNOW YOUR PLAN.................................7 MEDICAL......................................8 PRESCRIPTION DRUG.......... 17 FQHC........................................... 19 ADDITIONAL MEDICAL PLAN RESOURCES................. 20 WELLNESS PROGRAM......... 21 DENTAL...................................... 23 VISION........................................ 25 LIFE INSURANCE.................... 28 DISABILITY............................... 30 VOLUNTARY OFFERINGS... 31 EDUCATIONAL SUPPORT & CAREER DEVELOPMENT...................... 31 FINANCIAL WELL-BEING.... 32 HEALTH &WELLNESS.......... 33 SAVINGS.................................... 34 VOLUNTARY BENEFITS....... 35 SPENDING ACCOUNTS............................... 38 RETIREMENT BENEFITS................................... 39 CONTACTS................................ 41 LEGAL NOTICES....................... 43 WELLNESS CHECKLIST........ 45

AETNA SELECT PLAN HTC (Tier 2) Standard Plus Savings

Inner Circle (Tier 1) Maximum Savings

Aetna (Tier 3) Standard Savings

Medical Services

Deductible (per person/per family)

$0/$0

$250/$500

$350/$700

Out-of-Pocket Maximum (per person/per family) Facility Benefits Room & Board / Ancillary

$3,500 / $7,000

$250 copay per admit

$750 copay per admit

$1,250 copay per admit

Outpatient Facility Benefits Outpatient Surgery (Hospital Based)

$50 copay

$400 copay

$750 copay

Outpatient Surgery (Surgical Center)

$50 copay

$400 copay

$750 copay

Physician Services Surgeon

Covered 100%

Covered 100% after deductible Covered 100% after deductible

Anesthesia

Covered 100%

Covered 100% after deductible Covered 100% after deductible

Inpatient Physician Visit

Covered 100%

Covered 100% after deductible Covered 100% after deductible

Physician Office Visits -Primary Care

$10 copay

$40 copay

$60 copay

Physician Office Visits - Specialist

$15 copay

$55 copay

$75 copay

Physician Office Visits - Routine Well Care

$0 copay

$0 copay

$0 copay

Supplemental Services Telemedicine

$5 copay

$20 copay

$20 copay

Urgent Care

$25 copay

$75 copay

$90 copay

Emergency Services

$200 copay

$200 copay

$200 copay

Diagnostic X-ray and Lab - Cost share for diagnostic X-Ray and Lab when performed as part of a physician office visit Outpatient X-ray and Lab - Performed in an outpatient hospital or independent lab.

Covered 100% no deductible Covered 100% no deductible Covered 100% no deductible

Covered 100% after $10 copay Covered 100% after $40 copay Covered 100% after $60 copay

Diagnostic hi-tech imaging

$10 copay

$125 copay

$150 copay

Covered 100% no deductible, copay waived

Covered 100% no deductible, copay waived

Covered 100% no deductible, copay waived

Routine Vision Exam annually

Non-Routine Vision Exams

$15 copay

$55 copay

$75 copay

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. * AtlantiCare also covers some services for gender assignment. Check the plan document for more information.

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