2026 AtlantiCare Benefits Booklet

MEDICAL (CONT.)

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

Features of the Select Plan: Three-levels of providers and benefits. The Select Plan covers the same services across all three tiers noted above; however, the amount of your cost sharing will vary based on the tier designation of the provider fromwhom you receive care: 1) Inner Circle Tier 1 (AtlantiCare and its affiliates): when you receive care from an Inner Circle provider, you will have the least amount of cost-sharing and you will not be required to meet a deductible. 2) After the Inner Circle, the remaining participating doctors and hospitals are grouped into two tiers – HTC Tier 2 and Aetna Tier 3. Your out-of-pocket costs depend on which tier the doctor or hospital is in. For example: a. HTC Tier 2 : With this tier, there is more member cost- sharing required than the Inner Circle as reimbursement for covered services will be subject to a deductible of $250 for individual coverage and $500 for family coverage. b. Aetna Tier 3 : This tier includes all other Aetna In-Network providers that are neither Inner Circle nor HTC Tier 2 providers. Tier 3 also includes all Aetna providers that participate in the national Aetna network. When you use Tier 3 providers, you will have the highest amount of cost sharing. There is a deductible of $350 for individual coverage and $700 for family coverage; and the copays for covered services are the highest amongst all tiers, reaching up to $1,250 for some services.

If services are not available from Inner Circle providers, your cost sharing responsibility will be at the HTC Tier 2 or Aetna Tier 3 level of coverage. The level of cost sharing will be based on the tier status of the provider fromwhom you receive care. • The deductibles will cross-apply between all applicable tiers, meaning that the deductible amounts incurred under HTC Tier 2 will also be counted towards Aetna Tier 3 deductibles (and vice versa). For family coverage, if an individual within the family unit satisfies the individual deductible amount, the plan will pay benefits for that individual even if the family deductible is not satisfied. • There are no out-of-network benefits under the Select plan (with the exception for emergency situations). • The below chart provides a visual outline of the plan’s tiers and corresponding member cost-share.

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