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Horizon Low Plan Horizon Mid Plan Horizon High PlanPlan Name OMNIA HSA 12 EPO EE EPO DEIn Network Benefits Deductible (Employee / Family)T1: $2,000 / $4,000T2: $2,500 / $5,000 $1,500 / $3,000 $1,000 / $2,000 Coinsurance (Member / Carrier)T1: 20%T2: 50% 70% / 30% 80% / 20%Maximum Out of Pocket Cost (MOOP)(Employee / Family)T1: $4,500 / $9,000T2: $6,650 / $13,300 $4,000 / $8,000 $3,500 / $7,000Primary Care Provider (PCP) Copay T1 $20 Copay / T2 $40 Copay $20 Copay $20 CopayWellness & Preventative Covered at 100% Covered at 100% Covered at 100%Specialist Copay T1 $40 Copay / T2 $40 Copay $40 Copay $40 CopayTelemedicine Copay $15 Copay $15 Copay $15 CopayInpatient Hospitalization T1: 20% Coinsurance after DeductibleT2: 50% Coinsurance after Deductible Deductible + 30% Coinsurance%u00a0 Deductible + 20% Coinsurance%u00a0Outpatient Facility T1: 20% Coinsurance after DeductibleT2: 50% Coinsurance after Deductible Deductible + 30% Coinsurance%u00a0 Deductible + 20% Coinsurance%u00a0Emergency Room $100 Copay, waived if admitted $100 Copay -%u00a0waived if admitted $100 Copay -%u00a0waived if admittedUrgent Care T1 $40 Copay / T2 $50 Copay $40 Copay $40 CopayLaboratory T1: 20% Coinsurance after DeductibleT2: 50% Coinsurance after DeductibleOffice Setting: No Charge Free Standing Lab: 30% CoinsuranceOffice Setting: No Charge Free Standing Lab: 30% CoinsuranceX-RayT1: 20% Coinsurance after DeductibleT2: 50% Coinsurance after DeductibleOffice Setting: No Charge Free Standing Lab: 30% CoinsuranceOffice Setting: No Charge Free Standing Lab: 30% CoinsuranceImaging (CT, MRI, PET) T1: 20% Coinsurance after DeductibleT2: 50% Coinsurance after Deductible Deductible + 30% Coinsurance%u00a0 Deductible + 20% Coinsurance%u00a0Benefit Period Calendar Year Calendar Year Calendar YearGatekeeper Non-gated Non-gated Non-gatedOut-of-Network Benefits Deductible (Employee / Family)Emergency Only Emergency Only Emergency Only Coinsurance (Member / Carrier)Maximum Out of Pocket Cost (MOOP)(Employee / Family)Prescription Benefits Generic Preferred BrandNon-preferred Brand40%/ 40%/ 40% $15/$50/$75 $15 / $50 / $75Deductible N/A N/A N/AHealth PlansHealth and Prescription Plan Design FeaturesThe following chart summarizes each plan%u2019s design, along with the amounts you pay when you use in-network providers.This chart shows how the plan works and how each type of service is covered:7