Horizon Medicare Advantage

Comparison

Choose your MA or MA-PD plan...

	Horizon Medicare Blue Value (HMO)
	In Network
Choice of health care specialists	Must use network health care specialists
Annual deductible	$0 $10,000 maximum (out-of-pocket limit)
Hospital coverage	$175 copay per day for days 1-10. $1,750 out-of-pocket limit every stay
Outpatient hospital services/surgery	$35 - $200 copay
Doctor office visits	$15 PCP copay, $35 specialist copay
Emergency care (worldwide)	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.
Skilled nursing facility	$0 copay days 1-15; $85 copay days 16-30; $110 copay days 31-100
Home health care	$0 copay
Diagnostic tests, X-rays, lab services and radiology services	$0 - $2001 copay, depending on the services
Durable medical equipment	20% coinsurance
Routine physical exams	$15 copay for one routine exam per year
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	$0 copay for Flu and Pneumonia Vaccine; $15 copay for Hepatitis B Vaccine
Routine vision services	$15 - $35 copay for annual routine eye exam; $100 limit for eyewear every two years
Dental services	$0 copay for one oral exam, one cleaning every six months and one dental X-ray every three years
Hearing services2	$15 - $35 copay for annual routine hearing exam; $750 hearing aid allowance every three years
Prescription drug coverage	Not covered
Premium	$0*

	Horizon Medicare Blue Value w/ Rx Standard (HMO)
	In Network
Choice of health care specialists	Must use network health care specialists
Annual deductible	$0 $10,000 maximum (out-of-pocket limit)
Hospital coverage	$150 copay per day for days 1-10. $1,500 out-of-pocket limit every stay
Outpatient hospital services/surgery	$35 - $125 copay
Doctor office visits	$15 PCP copay, $35 specialist copay
Emergency care (worldwide)	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.
Skilled nursing facility	$0 copay days 1-15; $85 copay days 16-30; $110 copay days 31-100
Home health care	$0 copay
Diagnostic tests, X-rays, lab services and radiology services	$0 - $1251 copay, depending on the services
Durable medical equipment	20% coinsurance
Routine physical exams	$15 copay for one routine exam per year
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	$0 copay for Flu and Pneumonia Vaccine; $15 copay for Hepatitis B Vaccine
Routine vision services	$15 - $35 copay for annual routine eye exam; $100 limit for eyewear every two years
Dental services	$0 copay for one oral exam, one cleaning every six months and one dental X-ray every three years
Hearing services2	$15 - $35 copay for annual routine hearing exam; $750 hearing aid allowance every three years
Prescription drug coverage	$310 deductible; $8 generic copay / $38 preferred brand copay / $76 non-preferred brand copay / 25% specialty coinsurance for annual drug costs between $311 and $2,830; no coverage for annual drug costs between $2,830 and $4,550. After your annual out-of-pocket drug costs exceed $4,550, you pay the greater of $2.50 copay for generic (including brand drugs treated as generic) and $6.30 copay for all other drugs or 5% coinsurance.
Premium	$62.00*

	Horizon Medicare Blue Value w/ Rx Enhanced (HMO)
	In Network
Choice of health care specialists	Must use network health care specialists
Annual deductible	$0 $10,000 maximum (out-of-pocket limit)
Hospital coverage	$150 copay per day for days 1-10. $1,500 out-of-pocket limit every stay
Outpatient hospital services/surgery	$35 - $125 copay
Doctor office visits	$15 PCP copay, $35 specialist copay
Emergency care (worldwide)	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.
Skilled nursing facility	$0 copay days 1-15; $85 copay days 16-30; $110 copay days 31-100
Home health care	$0 copay
Diagnostic tests, X-rays, lab services and radiology services	$0 - $1251 copay, depending on the services
Durable medical equipment	20% coinsurance
Routine physical exams	$15 copay for one routine exam per year
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	$0 copay for Flu and Pneumonia Vaccine; $15 copay for Hepatitis B Vaccine
Routine vision services	$15 - $35 copay for annual routine eye exam; $100 limit for eyewear every two years
Dental services	$0 copay for one oral exam, one cleaning every six months and one dental X-ray every three years
Hearing services2	$15 - $35 copay for annual routine hearing exam; $750 hearing aid allowance every three years
Prescription drug coverage	$8 generic copay / $37 preferred brand copay / $74 non-preferred brand copay / 33% specialty coinsurance for annual drug costs up to $2,830. For annual drug costs between $2,830 and $4,550, you pay $8 copay for generics for a one-month supply and 100% for all other prescriptions. After your annual out-of-pocket drug costs exceed $4,550, you pay the greater of $2.50 copay for generic (including brand drugs treated as generic) and $6.30 copay for all other drugs or 5% coinsurance.
Premium	$86.60*

	Horizon Medicare Blue Access (HMO-POS)
	In Network	Out of Network
Choice of health care specialists	Must use network health care specialists	Your choice
Annual deductible	$0 No out-of-pocket limit	$900 $6,200 maximum (out-of-pocket limit)
Hospital coverage	$75 copay per day for days 1-10 $750 out-of-pocket limit every stay	65% coverage
Outpatient hospital services/surgery	$35 - $125 copay	65% coverage
Doctor office visits	$15 PCP copay, $35 specialist copay	65% coverage
Emergency care (worldwide)	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.
Skilled nursing facility	$0 copay days 1-5 $50 copay days 6-22; $100 copay days 23-100	65% coverage
Home health care	$0 copay	65% coverage
Diagnostic tests, X-rays, lab services and radiology services	$0 - $1251 copay, depending on the services	65% coverage
Durable medical equipment	20% coinsurance	65% coverage
Routine physical exams	$15 copay for one routine exam per year	65% coverage
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	$0 copay for Flu and Pneumonia Vaccine; $15 copay for Hepatitis B Vaccine	65% coverage
Routine vision services	$15 - $35 copay for annual routine eye exam; $100 limit for eyewear every two years	65% coverage
Dental services	$0 copay for one oral exam, one cleaning every six months and one dental X-ray every three years	Not covered
Hearing services2	$15 - $35 copay for annual routine hearing exam $750 hearing aid allowance every three years	65% coverage
Prescription drug coverage	Not covered	Not covered
Premium	$38.30*

	Horizon Medicare Blue Access w/ Rx Standard (HMO-POS)
	In Network	Out of Network
Choice of health care specialists	Must use network health care specialists	Your choice
Annual deductible	$0 No out-of-pocket limit	$900 $6,200 maximum (out-of-pocket limit)
Hospital coverage	$75 copay per day for days 1-10 $750 out-of-pocket limit every stay	65% coverage
Outpatient hospital services/surgery	$35 - $125 copay	65% coverage
Doctor office visits	$15 PCP copay, $35 specialist copay	65% coverage
Emergency care (worldwide)	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.
Skilled nursing facility	$0 copay days 1-5 $50 copay days 6-22; $100 copay days 23-100	65% coverage
Home health care	$0 copay	65% coverage
Diagnostic tests, X-rays, lab services and radiology services	$0 - $1251 copay, depending on the services	65% coverage
Durable medical equipment	20% coinsurance	65% coverage
Routine physical exams	$15 copay for one routine exam per year	65% coverage
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	$0 copay for Flu and Pneumonia Vaccine; $15 copay for Hepatitis B Vaccine	65% coverage
Routine vision services	$15 - $35 copay for annual routine eye exam; $100 limit for eyewear every two years	65% coverage
Dental services	$0 copay for one oral exam, one cleaning every six months and one dental X-ray every three years	Not covered
Hearing services2	$15 - $35 copay for annual routine hearing exam $750 hearing aid allowance every three years	65% coverage
Prescription drug coverage	$310 deductible; $10 generic copay / $43 preferred brand copay / $86 non-preferred brand copay / 25% specialty coinsurance for annual drug costs between $311 and $2,830; no coverage for annual drug costs between $2,830 and $4,550. After your annual out-of-pocket drug costs exceed $4,550, you pay the greater of $2.50 copay for generic (including brand drugs treated as generic) and $6.30 copay for all other drugs or 5% coinsurance.	You will likely have to pay the pharmacy's full charge for the drugs and submit documentation to receive reimbursement.
Premium	$127.10*

	Horizon Medicare Blue Access w/ Rx Enhanced (HMO-POS)
	In Network	Out of Network
Choice of health care specialists	Must use network health care specialists	Your choice
Annual deductible	$0 No out-of-pocket limit	$900 $6,200 maximum (out-of-pocket limit)
Hospital coverage	$75 copay per day for days 1-10 $750 out-of-pocket limit every stay	65% coverage
Outpatient hospital services/surgery	$35 - $125 copay	65% coverage
Doctor office visits	$15 PCP copay, $35 specialist copay	65% coverage
Emergency care (worldwide)	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.	$50 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit.
Skilled nursing facility	$0 copay days 1-5 $50 copay days 6-22; $100 copay days 23-100	65% coverage
Home health care	$0 copay	65% coverage
Diagnostic tests, X-rays, lab services and radiology services	$0 - $1251 copay, depending on the services	65% coverage
Durable medical equipment	20% coinsurance	65% coverage
Routine physical exams	$15 copay for one routine exam per year	65% coverage
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	$0 copay for Flu and Pneumonia Vaccine; $15 copay for Hepatitis B Vaccine	65% coverage
Routine vision services	$15 - $35 copay for annual routine eye exam; $100 limit for eyewear every two years	65% coverage
Dental services	$0 copay for one oral exam, one cleaning every six months and one dental X-ray every three years	Not covered
Hearing services2	$15 - $35 copay for annual routine hearing exam $750 hearing aid allowance every three years	65% coverage
Prescription drug coverage	$8 generic copay / $37 preferred brand copay / $74 non-preferred brand copay / 33% specialty coinsurance for annual drug costs up to $2,830. For annual drug costs between $2,830 and $4,550 you pay $8 copay for generics for a one-month supply and 100% for all other prescriptions. After your annual out-of-pocket drug costs exceed $4,550, you pay the greater of $2.50 copay for generic (including brand drugs treated as generic) and $6.30 copay for all other drugs or 5% coinsurance.	You will likely have to pay the pharmacy's full charge for the drugs and submit documentation to receive reimbursement.
Premium	$152.90*

Please note: This is only a partial listing of benefits. For a complete listing of plan benefits, please see the Summary of Benefits.

¹ All lab services must be performed by LabCorp or AtlantiCare.
² Must use a HEARx facility or participating audiologists in counties where there are no HEARx facilities for in-network benefits.

*You must continue to pay your Medicare Part B premium if not otherwise paid for by Medicaid or by another third party.