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

Compare 2022 Plan Choices

Horizon Engaged Plan

PPO Plan

Medical Services

Inner Circle/Tier 1

Tier 2

Inner Circle/Tier 1

Tier 2

Out-of-Network

Supplemental Services

Covered 100% after $5 copay/visit

Covered 100% after $20 copay/visit

Covered 100% after $5 copay/visit

Covered 100% after $20 copay/visit Covered 100% after $50 copay/visit and deductible; all other services rendered in the office covered 70% after deductible Office and freestanding clinic: Covered 100% after $50 copay/visit and deductible Facility: Covered 70% after deductible Office and freestanding clinic: Covered at 70% after deductible for services performed at a freestanding facility or in an Office Facility: Covered 70% after deductible Covered 100% after $150 copay

Covered 100% after $20 copay/visit

Telemedicine

Covered 100% after $20 copay and deductible

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

Covered 100% after $20 copay and deductible

Urgent Care

Covered 100% after $60 copay

Covered 100% after $150 copay and deductible

Covered 100% after $150 copay and deductible

Covered 100% after $150 copay

Emergency Services

Covered 100% after $150 copay

Office and freestanding clinic: Covered 100% after $50 copay/visit and deductible

Covered 100% after $10 copay and deductible

Covered 100% after $10 copay/visit

Covered 50% after deductible

Diagnostic X-ray

Facility: Covered 70% after deductible

Covered at 70% after deductible for services performed at a freestanding facility or in an Office Facility: Covered 70% after deductible

Covered 100% after $10 copay and deductible

Diagnostic hi-tech imaging

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 100% after $10 copay/visit and deductible

Covered 100% after $50 copay/visit and deductible

Covered 100% after $10 copay/visit

Covered 70% after deductible

Covered 50% after deductible

Diagnostic Tests

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.

Vision care expense benefit for all plans (no network limitations) Routine Vision Exam annually $70 Eyeglasses and/or Contact Lenses every two years $60 Must submit a claim form for reimbursement.

*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.

13