| Coverage Description | Horizon HMO $30 |
| Primary Care Physician Copayment | $30 |
| Specialist Copayment | $30 |
| Deductible | N/A |
| Coinsurance | 50% for prescription drugs |
| Maximum Out of Pocket | N/A |
| Lifetime Benefit Maximum | Unlimited |
Inpatient Hospital
(Subject to preapproval) | $300 copayment per day for a maximum of 5 days per admission; $3,000 maximum per calendar year. |
| Ambulatory Surgical Center Facility Charges | $30 |
| Hospital Outpatient Facility Charges | $30 |
| Emergency Room Copayment | $100 (Credited toward inpatient admission if admitted within 24 hours.) |
Biologically Based Mental Illness and Alcoholism
(Inpatient is subject to preapproval) | Inpatient: $300 copayment per day for amaximum of 5 days per admission;$3,000 maximum per calendar year. |
| Non-Biologically Based Mental Illness and Substance Abuse | Inpatient (subject to preapproval):100% after the hospital copayment for a maximumof 30 days per year (1 inpatient day may beexchanged for 2 outpatient visits).Outpatient: 100% after the office copayment for amaximum 20 visits per calendar year. |
| Blood/Blood Products/Processing | Plan pays 100%. |
| Diagnostic X-ray/Lab | Office visit copayment per visit. |
Durable Medical Equipment
(Subject to preapproval) | Plan pays 100%. |
Home Health Care and Hospice Care
(Subject to preapproval) | Unlimited days. |
| Maternity | $25 copayment for the initial visit;
$0 copayment thereafter. |
| Prescription Drugs | 50% coinsurance. |
| Preventive Care | Office visit copayment per visit. |
Rehabilitation Centers
(Subject to preapproval) | Subject to inpatient hospital copayment above.Waived if immediately preceded by ahospital inpatient stay. |
| Speech, Physical (Subject to preapproval), Occupational and Cognitive Rehabilitation Therapies | $30 office visit copayment per visit. |
| Therapeutic Manipulations | Office visit copayment per visit. Limited to 30 visitsper calendar year and 2 modalities per visit. |
