AtlantiCare 2025 Benefits Booklet

MEDICAL (CONT.)

Compare 2025 Medical Plan Choices

Welcome.................................... 2 What’s New?............................. 3 How to Enroll........................... 4 Medical....................................... 6 Prescription Drug.................14 FQHC.........................................16 Additional Medical Plan Resources................................17 AtlantiCare Longevity Lifestyle Program................18 Dental.......................................20 Vision.........................................22 Life Insurance........................25 Disability..................................26 Voluntary Offerings.............27 Educational Support & Career Development..........27 Financial Well-being...........28 Health &Wellness................29 Savings.....................................31 Voluntary Benefits...............32 Spending Accounts.............35 Retirement Benefits............36 Contacts...................................38 Legal Notices.........................40 Wellness Checklist...............42

PPO Plan

Medical Services

Inner Circle

Tier 2

Out-of-Network

Deductible (per person/per family)

$0/$0

$250/$500

$1000/$2000

Out of Pocket Maximum (per person/per family)

$3,500/$7,000

$5,000/$10,000

Facility Benefits

$750 copay per admit after deductible

Room & Board / Ancillary

$250 copay per admit

Covered 50% after deductible

Outpatient Facility Benefits Outpatient Surgery (Hospital Based) Outpatient Surgery (Surgical Center)

$50 copay $50 copay

$400 copay $400 copay

Covered 50% after deductible Covered 50% after deductible

Physician Services Surgeon

Covered 100% Covered 100% after deductible Covered 100% Covered 100% after deductible Covered 100% Covered 100% after deductible

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

Anesthesia

Inpatient Physician Visit

Physician Office Visits - Primary Care

$10 copay $15 copay

$35 copay $50 copay

Physician Office Visits - Specialist

Physician Office Visits - Routine Well Care

$0 copay

$0 copay

Supplemental Services Telemedicine

$5 copay

$20 copay after deductible

$20 copay after deductible

Urgent Care

$25 copay

$60 copay

Covered 50% after deductible

Emergency Services

$200 copay $10 copay $10 copay $10 copay $10 copay

$200 copay

$200 copay

Diagnostic X-ray

$35 copay

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

Diagnostic hi-tech imaging

$100 copay after deductible

Diagnostic Tests (LabCorp/Quest Capitated Labs)

$35 copay $35 copay

Diagnostic Tests (Non-Capitated Labs)

Routine Vision Exam annually**

$70

Eyeglasses and/or Contact Lenses every two years**

$60

This chart is meant as an overview only. For detailed information, please refer to the Summary Plan Description posted under “Beneft Information” on the HR Portal: Benefts Tab. * AtlantiCare also covers some services for gender assignment. Check the plan document for more information. ** For vision, must submit a claim form for reimbursement.

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