AtlantiCare Benefits Book 2020

Medical

Compare 2020 Plan Choices

HOME TABL OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 I E TERS AND EBSITES...................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. ........26-29 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

Supplemental Services

Covered 100% after $20 copay/visit

Covered 100% after $20 copay/visit

Covered 100% after $20 copay/visit

Covered 100% after $20 copay/visit Covered 100% after $50 copay/visit and deductible; all other services rendered in the office covered 70% after deductible Office and freestanding clinic: Covered 100% after $50 copay/visit and deductible Facility: Covered 70% after deductible Office and freestanding clinic: Covered 100% after $50 copay/visit and deductible Covered 100% after $150 copay

Covered 100% after $20 copay/visit

Telemedicine

N/A

N/A

Covered 100% after $40 copay/visit and wellness deductible; all other services rendered in the office covered 80% after wellness deductible Covered 100% after $150 copay and wellness deductible Office and freestanding clinic: Covered 100% after $40 copay/visit and 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 $150 copay and wellness deductible Office and freestanding clinic: Covered 100% after $50 copay/visit and wellness deductible

Covered 100% after $20 copay and wellness deductible

Covered 100% after $20 copay and wellness deductible

Covered 100% after $20 copay and deductible

Covered 100% after $60 copay

Urgent Care

Covered 100% after $150 copay and wellness deductible

Covered 100% after $150 copay and wellness deductible

Covered 100% after $150 copay

Covered 100% after $150 copay

Emergency Services

Covered 100% after $10 copay and wellness deductible

Covered 100% after $10 copay and wellness deductible

Covered 100% after $10 copay/visit

Covered 50% after deductible

Diagnostic X-ray

Facility: Covered 80% after wellness deductible

Facility: Covered 70% after wellness deductible

Office and freestanding clinic: Covered 100% after $40 copay/visit and wellness deductible

Office and freestanding clinic: Covered 100% after $50 copay/visit and wellness deductible

Covered 100% after $10 copay and wellness deductible

Covered 100% after $10 copay and wellness deductible

Covered 100% after $10 copay/visit

Covered 50% after deductible

Diagnostic hi-tech imaging

Facility: Covered 80% after wellness deductible

Facility: Covered 70% after wellness deductible

Facility: Covered 70% after deductible

Covered 100% after $10 copay/visit and wellness deductible

Covered 100% after $40 copay/visit and wellness deductible

Covered 100% after $10 copay/visit and wellness deductible

Covered 100% after $50 copay/visit and wellness deductible

Covered 100% after $10 copay/visit

Covered 70% after deductible

Covered 50% after deductible

Diagnostic Tests

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.

Vision care expense benefit for all plans (no network limitations) Routine Vision Exam annually $70 Eyeglasses and/or Contact Lenses every two years $60 Must submit a claim form for reimbursement.

* 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.

FORMS

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