| Benefits |
Horizon Basic and Essential EPO Coverage |
Horizon Basic and Essential EPO Plus Coverage |
| Physician Services — Consultation, medical and surgical services, assistant surgeon, anesthesia and maternity care |
Outpatient/Out of hospital/Illness and injury office visits covered to $700 per covered person per calendar year
Wellness visits covered to $600 per covered person per calendar year after $50 deductible and 20% coinsurance
Inpatient practitioner's fees connected with inpatient hospital confinement are covered under inpatient hospital services |
Outpatient/Out of hospital/Office visits — $30 copayment per covered person per visit
Wellness visits covered to $600 per covered person per calendar year
Inpatient practitioner's fees connected with inpatient hospital confinement are covered under inpatient hospital services |
| Physical Therapy — Outpatient (30 visits per covered person per calendar year) |
$20 copayment per covered person per visit |
$20 copayment per covered person per visit |
| Maternity Services — Physician Services |
Delivery charge covered; pre- and post-natal charges are covered when included in the delivery charge |
$30 copayment for initial visit; inpatient stay subject to inpatient hospital charges |
| Inpatient Hospital Services (90 days per covered person per calendar year) |
$500 copayment per covered person per period of confinement |
$500 copayment per covered person per period of confinement |
| Outpatient Hospital Services Outpatient Surgery and Ambulatory Surgery |
$250 copayment per covered person per surgery |
$250 copayment per covered person per surgery |
| Out-of-Hospital Diagnostic Tests |
$500 maximum per covered person per calendar year |
$500 maximum per covered person per calendar year |
| Emergency Room Services |
$100 copayment per covered person per visit (waived if admitted) |
$100 copayment per covered person per visit (waived if admitted) |
| Alcohol and Substance Abuse — Inpatient (30 days per covered person per calendar year) |
30% coinsurance after $500 hospital confinement copayment |
30% coinsurance after $500 hospital confinement copayment |
| Alcohol and Substance Abuse — Outpatient (30 visits per covered person per calendar year) |
30% coinsurance |
30% coinsurance |
| Mental Illness (BBMI) — Inpatient (90 days per covered person per calendar year) |
$500 copayment per covered person per period of confinement |
$500 copayment per covered person per period of confinement |
| Mental Illness (BBMI) — Outpatient (30 visits per covered person per calendar year) |
30% coinsurance |
30% coinsurance |
| Prescription Drugs (Obtained while not confined in a hospital) |
Not covered |
$15 copayment for generic drugs with one copayment per 30-day supply for retail and mail order;
50% coinsurance for brand-name drugs up to $500 maximum per covered person per calendar year |
| Home Health Care |
Not covered |
50% coinsurance up to $2,500 maximum per covered person per calendar year |
| Durable Medical Equipment |
Not covered |
50% coinsurance up to $2,500 maximum per covered person per calendar year |
| Hospice Care |
Not covered |
50% coinsurance up to $2,500 maximum per covered person per calendar year |
| Diabetes Benefits |
Not covered |
50% coinsurance up to $2,500 maximum per covered person per calendar year |
| Birthing Center Confinement |
Birthing Center charges not covered |
$250 copayment per covered person per period of confinement |
| Rehabilitation Center Confinement |
Rehabilitation Center charges not covered |
$500 copayment per covered person per period of confinement; the copayment does not apply if admission is preceded by a hospital confinement; maximum 90 days per calendar year |
| Casts, braces, trusses, prosthetic devices, orthopedic footwear and crutches |
Not covered |
Casts, prosthetic devices and crutches are covered |
| Chemotherapy, Infusion Therapy |
Not covered |
Covered |
| Transplants |
Not covered |
Covered |
Exclusions** |
Horizon Basic and Essential EPO Coverage |
Horizon Basic and Essential EPO Plus Coverage |
| Ambulance, Routine Foot Care, Skilled Nursing Facility charges, Skilled Nursing Care charges, Therapeutic Manipulation (Chiropractic), Treatment of a Non-Biologically Based Mental Illness |
Not covered |
Not covered |
