AtlantiCare 2022 Benefits Booklet

Medical Compare 2022 Plan Choices

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

Horizon Engaged Plan

PPO Plan

Medical Services

Inner Circle/Tier 1

Tier 2

Inner Circle/Tier 1

Tier 2

Out-of-Network

Deductible (per person/per family)

$2,000/$4,000

$2,500/$5,000*

N/A

$1,000/$2,000

$2,000/$4,000

*Wellness credits can reduce deductible to $500/1,000

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

$6,950/$13,900

$6,950/$13,900

$8,800/$17,600

Facility Benefits

Covered 100% after deductible

Covered 100% after $1,250 copay/visit and deductible

Covered 100% after deductible

Covered 100% after $750 copay/visit

$2,000 copay/visit then covered 50%; no deductible

Room & Board / Ancillary

Outpatient Facility Benefits

Covered 100% after $25 copay and deductible Covered 100% after $25 copay and deductible Covered 100% after deductible Covered 100% after deductible Covered 100% after deductible

Outpatient Surgery (Hospital Based)

Covered 70% after $1,000 copay/visit and deductible

Covered 100% after $25 copay

Covered 100% after $750 copay/visit

$2,000 copay/visit then covered 50%; no deductible

Outpatient Surgery (Surgical Center)

Covered 70% after $750 copay/visit and deductible

Covered 100% after $25 copay

Covered 100% after $500 copay/visit

Covered 50% after deductible

Physician Services

Covered 70% after deductible Covered 70% after deductible Covered 70% after deductible Covered 100% after $50 copay/visit; all other services rendered in the office covered 70% after deductible Covered 100% after $65 copay/visit; all other services rendered in the office covered 70% after deductible

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

Surgeon

Covered 70% after deductible

Covered 100%

Anesthesia

Covered 70% after deductible

Covered 100%

Inpatient Physician Visit

Covered 70% after deductible

Covered 100%

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

Covered 100% after $10 copay and deductible

Physician Office Visits - Primary Care

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 100% after $65 copay/visit and wellness deductible; all other services rendered in the office covered 70% after deductible

Covered 100% after $10 copay and deductible

Physician Office Visits - Specialist

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 50% after deductible

Physician Office Visits - Routine Well Care

Covered 100%

Covered 100%

Covered 100% Covered 100%

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. * 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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