Page 5 - SEARCH Day Program Benefit Guide 2020-2021

A GUIDE TO YOUR BENEFITS | 2020

Medical Coverage - Open Access Plans

Horizon offers a choice of medical plan options so you can choose the plan that best meets your needs and those of your family. Each
plan includes comprehensive health care benefits, including free preventive care services and coverage for prescription drugs.

Direct Access DA Direct Access POS EPO
In-Network
Plan Provision In-Network Out-of-Network In-Network Out-of-
Network 100%
Coinsurance N/A
100% 80% 100% 60%
Annual Deductible $3,000 / $6,000
(Individual/Family) N/A $250 / $500 N/A $1,000 / $2,000 100%

Out-of-Pocket Maximum $1,000 / $2,000 $4,000 / $8,000 $30 copay
(Includes Deductible) $50 copay
100% 80% 100% 60%
Preventive Care $10 copay $20 copay 100%
$10 copay Deductible, then $20 copay Deductible,
Physician Office Visit 80% then 60% 100%

Specialist Office Visit Deductible, then Deductible, $500 copay
80% then 60%
X-Ray and Lab $100 copay
Diagnostics 100% Deductible, then 100% Deductible,
80% then 60% $10 copay
X-Ray and Lab $25 copay
Complex Imaging 100% Deductible, then 100% Deductible, $50 copay
80% then 60%
Inpatient Hospital $20 copay
Services 100% Deductible, then 100% Deductible, $50 copay
80% then 60% $100 copay
Emergency Room Care
$50 copay $50 copay
Retail Prescription Drugs
(30-day supply) $5 copay $10 copay
• Tier 1 $15 copay $25 copay
• Tier 2 $30 copay $50 copay
• Tier 3
Mail Order Prescription $10 copay $20 copay
Drugs (90-day supply) $30 copay $50 copay
• Tier 1 $60 copay $100 copay
• Tier 2
• Tier 3 5|P a g e