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

! EXTRA FACTS ABOUT YOUR HORIZON PLANS • Your medical plan offers coverage for eye exams and vision hardware • Horizon’s Blue365 discount plan offers nationwide discounts on health and wellness products and services • You can connect with Horizon’s online services to access explanation of benefits (EOBs), claim forms, health news updates and chat services

Horizon Preferred Provide Plan (PPO) continued • Utilizing AtlantiCare and its affiliates for service will result in the lowest out-of-pocket cost. • Some services performed through a Blue Cross Blue Shield network provider will be covered at 70% after the deductible is met. • When you use the Blue Cross Blue Shield network, services will usually be paid at 50% after the deductible is met. • If services are not available at AtlantiCare, your responsibility will be at the Tier 2 or Out-of-Network level of coverage. For both plans visit http://atlanticare.horizonblue.com to find a participating physician, facility or other service provider.

The Plans At A Glance

HORIZON ENGAGED HORIZON PPO

Has AtlantiCare Network

Has “Out-of-Network” Providers

Has $1,000 Copay When Using Non-AtlantiCare Facilities

Lowest Contributions

Wellness Credits Reduce Deductible

Wellness Credits Reduce Contributions

Access to Telehealth Benefit

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