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

You have two choices in Medical Plan coverage: • Horizon Engaged Plan • Horizon Preferred Provider (PPO) Plan

You have two choices in medical plan options administered by Horizon Blue Cross Blue Shield: Horizon Engaged Plan and Horizon Preferred Provider (PPO). Horizon Blue Cross Blue Shield Blue Card provides access to one of the broadest networks in the country. Both options include access to AtlantiCare Inner Circle (Tier 1) physicians and you pay less when you are able to use these providers. Horizon Engaged Plan The Horizon Engaged Plan offers a lower biweekly contribution in return for your commitment to engage in your health. You will have the opportunity to complete activities to earn wellness credits that will reduce the deductible up to $2,000 for single coverage and up to $4,000 for spouse or family coverage (wellness credits do not apply to children) that will be applied the following year . For a complete description of activities, please refer to the “Wellness” section in this booklet. You will need to complete these activities by their specific due date to earn the associated wellness credits. Features • Wellness credits earned reduce the deductible. • Two-tiered network of providers – AtlantiCare Tier (Inner Circle/ Tier1) and the Blue Cross Blue Shield (Tier 2) • Providers in both tiers are considered in-network providers but pay differently. This means that the same services are covered in both tiers, but when you utilize AtlantiCare and its affiliates, you pay less out-of-pocket. • When you use the Blue Cross Blue Shield Tier you have additional costs. In some cases, the additional costs could be up to a $1,000 copay and then 30% of the cost of services. • This plan does not cover physicians and facilities who do not participate in the national Blue Cross Blue Shield network. • If services are not available at AtlantiCare, your responsibility will be at the Tier 2 level of coverage.

Horizon Preferred Provider Plan (PPO) The Horizon Preferred Provider Plan includes the same benefits and provider network as the Horizon Engaged Plan but also offers coverage for physicians and facilities outside of the national Blue Cross Blue Shield network. This plan is the most expensive when it comes to how much you contribute each pay period. However, your pay cost can be reduced if you complete wellness activities. By completing wellness activities, you can earn up to $750 for single coverage and up to $1,500 for spouse or family coverage (wellness credits do not apply to children). Earned wellness credits are applied to the total cost of your medical contribution and divided over 26 pay periods for the following year. For a complete description of activities, please refer to the “Wellness” section in this booklet. You will need to complete these activities by their specific due date to earn the associated wellness credits. Features • Wellness credits earned reduce your contributions. • Includes the same benefits and provider networks as the Horizon Engaged Plan, but also offers coverage for physicians and facilities outside of the national Blue Cross Blue Shield network.

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