Page 4 - FantaSea 2021 Benefits Guide

Medical Coverage
The Company offers a choice of medical plan options with Horizon Blue Cross Blue Shield; you choose the plan
that 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.

Plan 1 - $ Plan 2 - $$ Plan 3 - $$$
Plan Provisions In- Network Out-of- Out-of-
In- Network Tier 1 In- Network In- Network
Tier 2 Network Network
Horizon Network OMNIA HSA Design 12 Advantage EPO Design 3 Advantage EPO Design 4
Deductible $2,000/$4,000 $2,500/$5,000 $2,500/$5,000 $1,500/$3,000
(Ind/Family)
Out-of-Pocket
Max. (Includes $4,500/$9,000 $6,650/$13,300 $5,000/$10,000 $4,000/$8,000
Deductible)
(Ind/Family)

Coinsurance 80% 50% 70% 50%

Preventive Care 100% Not Covered Not Covered
100% 100% 100%
Primary Care $20, after ded $40, after ded $30 Copay $30 Copay
Physician

Specialist $40, after ded $50, after ded $50 Copay $50 Copay
Inpatient
Hospital 80%, after ded
Services 50%, after ded 70% after ded 50%, after ded
Outpatient 80%, after ded
Hospital Services
Urgent Care $50 Copay $50 Copay
$40, after ded $50, after ded
Emergency
Room Care 80% after $100 Copay and ded 70% after $100 Copay 50% after $100 Copay
Retail
Prescriptions
30-day supply 30-day supply
(30- day supply) 30-day supply $15 copay $15 Copay
Generic 60% after Tier 1 deductible $50 copay $50 Copay
$75 copay
Preferred $75 Copay
Non-preferred Not
Mail Order Not Covered Covered
Prescriptions
(90-day 90-day supply 90-day supply 90-day supply
supply)
Generic 60% after Tier 1 deductible 2.5x Retail 2.5x Retail
Preferred
Non-preferred

FANTASEA RESORTS