| 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 |
