AtlantiCare 2022 Benefits Booklet

Medical

TABLE OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 SERVICE CENTERS AND WEBSITES..........4 HOW TO ENROLL....5-6 MEDICAL..............7-13 PRESCRIPTION DRUG. ................14-16 ADDITIONAL MEDICAL PLAN RESOURCES........17-22 DENTAL...............24-25 VISION.....................26 LIFECENTER..............27 LIFE INSURANCE. .....28 DISABILITY...............29 VOLUNTARY OFFERINGS. ........30-33 SPENDING ACCOUNTS. ............34 RETIREMENT BENEFITS..................35 WELLNESS. .........36-39 LEGAL NOTICES...40-42 GLOSSARY..........43-44 FAQs...................45-47 CONTACTS.........48-49 FORMS................50-56

2022 Medical Plan Bi-Weekly Contribution Rates

Full-Time

Part-Time

$0-49,999k $50-109,999k $110,000-199,999k

$200k+

$0-49,999k $50-109,999k $110,000-199,999k $200k+

Horizon Engaged Plan

Employee

$38.10 $46.11

$84.99

$94.01 $76.08 $87.69

$169.97

$188.00

Employee + Spouse

$65.25 $78.96

$145.54

$160.99 $130.28 $150.16

$291.07

$321.94

Employee + Child(ren)

$52.59 $63.64

$117.34

$129.76 $105.01 $121.04

$234.61

$259.50

Family

$104.20 $126.08

$232.40

$257.08 $208.03 $239.78

$464.79

$514.10

Horizon PPO

Employee

$151.76 $167.32

$208.54

$217.27 $179.71 $198.13

$323.40

$337.97

Employee + Spouse

$259.89 $286.54

$357.12

$372.06 $307.76 $339.30

$555.54

$578.79

Employee + Child(ren)

$209.47 $230.96

$287.86

$299.92 $248.07 $273.49

$ 447.77 $466.50

Family

$415.00 $457.53

$570.27

$594.14 $491.44 $541.81

$887.10

$924.24

*$25 surcharge will be added to your bi-weekly deductions if you utilize tobacco products. A Spouse & Partner Preferred Choice Premium may also apply. See page 9 for details. ** Note, salary changes may result in changes to your contribution rate

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