AtlantiCare 2025 Benefits Booklet

MEDICAL (CONT.)

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

• If services are not available from Inner Circle providers, your cost sharing responsibility will be at the OMNIA Tier 1 or Tier 2 level of coverage. The level of cost sharing will be based on the tier status of the provider from whom you receive care.

• The deductibles will cross-apply between all applicable tiers, meaning that the deductible amounts incurred under OMNIA Tier 1 will also be counted towards Tier 2 deductibles (and vice versa). For family coverage, if an individual within the family unit satisfies the individual deductible amount, the plan will pay benefits for that individual even if the family deductible is not satisfied. • There are no out-of-network benefits under the OMNIA plan (with the exception for emergency situations). • The adjacent chart provides a visual outline of the plan’s tiers and corresponding member cost-share. Horizon Preferred Provider (PPO) Plan The Horizon Preferred Provider Plan covers the same services as the OMNIA Plan and includes two levels of In-Network benefits as well as reimbursement for non participating (i.e. Out-of-Network) physicians and facilities. This plan is the most expensive when it comes to how much you contribute each pay period, but you have greater flexibility in where you can seek medical care. An AtlantiCare-funded Health Reimbursement Account (HRA) will be available to you through wellness credits earned in 2024. Features of the Preferred Provider (PPO) Plan: • Three levels of providers and benefits: 1) Inner Circle (AtlantiCare and its affiliates) providers: no deductibles, lowest copays and and the least amount out-of-pocket costs

2) In-Network (Horizon PPO or national BlueCard networks): after satisfying a deductible and/or a copay, benefits are covered at 100% 3) Out-of-Network (non-participating): most cost sharing – covered services are reimbursed at 50% after the deductible. It is also important to note that an Out-of-Network provider may “balance bill”for any amounts in the event their charges are over what is considered over the reasonable and customary charge. Charges that are balanced billed are not counted towards the Plan’s out-of-pocket maximum limits. • If services are not available at AtlantiCare, your responsibility will be at either the In-Network or Out-of-Network level of coverage. For both plans, visit https://www.horizonblue.com/atlanticare to find a participating physician, facility or other service provider.

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