| Coverage Description | Horizon Basic Plan A/50 |
| Annual Deductible | $1,000 Individual/$2,000 Family (Aggregate).
$2,500 Individual/$5,000 Family (Aggregate).
$5,000 Individual/$10,000 Family (Aggregate).
$10,000 Individual/$20,000 Family (Aggregate). |
| Coinsurance | Plan pays 50%/You pay 50%. |
Maximum Out of Pocket
(Does not include prescription drug coverage) | $6,000 Individual/$12,000 Family.
$7,500 Individual/$15,000 Family.
$10,000 Individual/$20,000 Family.
$15,000 Individual/$30,000 Family. |
| Lifetime Benefit Maximum | Unlimited |
| Office Visits | Subject to annual deductible and coinsurance. |
Inpatient Hospital: Semi-Private Inpatient Services and Supplies
(Subject to preapproval.) | 365 days a year. Subject to annual deductible and coinsurance. |
Extended Care of Rehabilitation Services
(Subject to preapproval.) | Subject to annual deductible and coinsurance. Limited to 120 days combined per year. |
| Emergency Room | $100 copayment (waived if admitted within 24 hours). Subject to annual deductible and coinsurance. |
Home Health Care
(Subject to preapproval.) | Subject to annual deductible and coinsurance. |
Hospice Care
(Subject to preapproval.) | Subject to annual deductible and coinsurance. |
| Biologically Based Mental Illness | Inpatient and Outpatient: Subject to
the annual deductible and 50%/50% coinsurance. |
| Non-Biologically Based Mental Illness and Substance Abuse | Inpatient and Outpatient: Subject to annual deductible and coinsurance. Inpatient confinement: 30 days per calender year. Outpatient: 20 visits per calender year. One inpatient day may be exchanged for two outpatient visits. |
Alcoholism
(Subject to preapproval.) | Inpatient and Outpatient:
Subject to annual deductible and coinsurance. |
| Practitioner’s Charge | Subject to annual deductible and coinsurance. |
| Preventive Care | $500 per individual (except newborns) per year. Newborns: $750 per year maximum benefit up to age 1. Not subject to annual deductible and coinsurance. |
| Maternity | Subject to annual deductible and coinsurance. |
| Therapy Services | Subject to annual deductible and coinsurance. Cognitive rehabilitation therapy, occupational therapy, physical therapy, and speech therapy limited to 30 visits per calendar year. Radiation therapy, chemotherapy, chelation therapy, dialysis treatment, and respiration therapy covered as any other illness. Infusion therapy subject to preapproval. |
| Therapeutic Manipulations | Subject to annual deductible and coinsurance. Limited to 30 visits per calender year. |
| Prescription Drugs | Subject to annual deductible and coinsurance. |
Durable Medical Equipment
(Subject to preapproval.) | Subject to annual deductible and coinsurance. |
| Blood/Blood Products/Processing | Subject to annual deductible and coinsurance. |
