AtlantiCare Benefits Book 2020

Medical

Compare 2020 Plan Choices

HOME TABL OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 I E TERS AND WEBSITES...................4 HO TO ENROLL.......5 MEDICAL..............6-12 PRESCRIPTION DRUG. ................13-15 ADDITIONAL MEDICAL PLAN RESOURCES........16-18 DENTAL...............19-21 VISION.....................22 LIFECENTER..............23 LIFE INSURANCE. .....24 LONG TERM DISABILITY...............25 VOLUNTARY OFFERINGS. ..... A26-29 SPENDING ACCOU TS. ............30 RETIREMENT B NEFITS..................31 WELLNESS. .........32-36 LEGAL NOTICES..37-39 CONTACTS.........40-41 GLOSSARY..........42-43 FAQs...................44-46 FORMS................47-56 WHAT’S NEW SERVICE CENTERS AND WEBSITES HOW TO ENROLL MEDICAL PRESCRIPTION DRUG ADDITIONAL MEDICAL PLAN RESOURCES DENTAL VISION LIFE INSURANCE LONG TERM DISABILITY VOLUNTARY OFFERINGS SPENDING ACCOUNTS RETIREMENT BENEFITS WELLNESS LEGAL NOTICES CONTACTS GLOSSARY

Geisinger Engaged Plan

Horizon Engaged Plan

PPO Plan

Medical Services

Tier 1

Tier 2

Inner Circle/Tier 1

Tier 2

Inner Circle/Tier 1

Tier 2

Out-of-Network

Wellness Deductible (per person/per family)

$2,000/$4,000*

$2,000/$4,000*

$2,000/$4,000*

$2,000/$4,000*

N/A

$1,000/$2,000

$2,000/$4,000

Out-of-Pocket Maximum after Deductible (per person/per family)

$8,150/$16,300

$8,150/$16,300

$8,150/$16,300

$8,500/$16,600

Facility Benefits

Covered 100% after $750 copay/visit and wellness deductible

Covered 100% after $1,000 copay/visit and wellness deductible

$2,000 copay/visit then covered 50%; no deductible

Covered 100% after wellness deductible

Covered 100% after wellness deductible

Covered 100% after deductible

Covered 100% after $750 copay/visit

Room & Board / Ancillary

Outpatient Facility Benefits

Covered 100% after $25 copay and wellness deductible Covered 100% after $25 copay and wellness deductible Covered 100% after wellness deductible Covered 100% after wellness deductible Covered 100% after wellness deductible

Covered 100% after $750 copay/visit and wellness deductible Covered 100% after $500 copay/visit and wellness deductible Covered 80% after wellness deductible Covered 80% after wellness deductible Covered 80% after wellness deductible

Covered 100% after $25 copay and wellness deductible Covered 100% after $25 copay and wellness deductible Covered 100% after wellness deductible Covered 100% after wellness deductible Covered 100% after wellness deductible

Covered 70% after $1,000 copay/visit and wellness deductible Covered 70% after $750 copay/visit and wellness deductible Covered 70% after wellness deductible Covered 70% after wellness deductible Covered 70% after wellness deductible Covered 100% after $50 copay/visit and wellness deductible; all other services rendered in the office covered 70% after wellness deductible Covered 100% after $65 copay/visit and wellness deductible; all other services rendered in the office covered 70% after wellness deductible

$2,000 copay/visit then covered 50%; no deductible

Outpatient Surgery (Hospital Based)

Covered 100% after $25 copay

Covered 100% after $750 copay/visit

Outpatient Surgery (Surgical Center)

Covered 100% after $25 copay

Covered 100% after $500 copay/visit

Covered 50% after deductible

Physician Services

Covered 70% after deductible Covered 70% after deductible Covered 70% after deductible Covered 100% after $50 copay/visit; all other services rendered in the office covered 70% after deductible Covered 100% after $65 copay/visit; all other services rendered in the office covered 70% after deductible

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

Surgeon

Covered 100%

Anesthesia

Covered 100%

Inpatient Physician Visit

Covered 100%

Covered 100% after $40 copay/visit and wellness deductible; all other services rendered in the office covered 80% after wellness deductible Covered 100% after $55 copay/visit and wellness deductible; all other services rendered in the office covered 80% after wellness deductible

Covered 100% after $10 copay and wellness deductible

Covered 100% after $10 copay and wellness deductible

Physician Office Visits - Primary Care

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 100% after $10 copay and wellness deductible

Covered 100% after $10 copay and wellness deductible

Physician Office Visits - Specialist

Covered 100% after $10 copay/visit

Covered 50% after deductible

Covered 50% after deductible

Physician Office Visits - Routine Well Care

Covered 100%

Covered 100%

Covered 100%

Covered 100%

Covered 100% Covered 100%

FORMS

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. * For Engaged Plans only, the wellness deductible can be reduced through wellness credits ** AtlantiCare also covers some services for gender assignment. Check the plan document for more information.

11