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 Choice Plan

Inner Circle (Tier 1) Maximum Savings

HTC (Tier 2) Standard Plus Savings

Aetna (Tier 3) Standard Savings

Medical Services

Out-of-Network

Deductible (per person/per family)

$0/$0

$150/$300

$350/$700

$1,000/$2,000

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

$3,500 / $7,000

$5,000/$10,000

Facility Benefits

$500 copay per admit after deductible

$1,000 copay per admit after deductible

Room & Board / Ancillary

$250 copay per admit

Covered 50% after deductible

Outpatient Facility Benefits

Outpatient Surgery (Hospital Based)

$50 copay

$300 copay

$600 copay

Covered 50% after deductible

Outpatient Surgery (Surgical Center)

$50 copay

$300 copay

$600 copay

Covered 50% after deductible

Physician Services

Surgeon

Covered 100%

Covered 100% after deductible Covered 100% after deductible Covered 50% after deductible

Anesthesia

Covered 100%

Covered 100% after deductible Covered 100% after deductible Covered 50% after deductible

Inpatient Physician Visit

Covered 100%

Covered 100% after deductible Covered 100% after deductible Covered 50% after deductible

Physician Office Visits -Primary Care

$10 copay

$30 copay

$50 copay

Covered 50% after deductible

Physician Office Visits - Specialist

$15 copay

$45 copay

$65 copay

Covered 50% after deductible

Physician Office Visits - Routine Well Care

$0 copay

$0 copay

$0 copay

Covered 50% after deductible

Supplemental Services

Telemedicine

$5 copay

$20 copay after deductible

$20 copay after deductible

N/A

Urgent Care

$25 copay

$75 copay

$90 copay

Covered 50% after deductible

Emergency Services

$200 copay

$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 50% after deductible

Covered 100% after $10 copay

Covered 100% after $30 copay Covered 100% after $50 copay

Covered 50% after deductible

Diagnostic hi-tech imaging

$10 copay

$100 copay

$150 copy

Covered 50% after deductible

Covered 100% no deductible, copay waived

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

$45 copay

$65 copay

Covered 50% after deductible

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.

– 14 – – –