| Coverage Description |
Horizon HMO Coinsurance |
| Primary Care Physician Copayment |
$40 |
|
Specialist Copayment |
Subject to deductible and coinsurance. |
|
Deductible |
$2,500 Individual / $5,000 Family Deductible (Aggregate) |
|
Coinsurance |
50% Coinsurance |
|
Maximum Out of Pocket |
$5,000 Individual / $10,000 Family |
|
Lifetime Benefit Maximum |
Unlimited |
Inpatient Hospital
(Subject to preapproval) |
Subject to deductible and coinsurance. |
|
Ambulatory Surgical Center Facility Charges |
Subject to deductible and coinsurance. |
|
Hospital Outpatient Facility Charges |
Subject to deductible and coinsurance. |
|
Emergency Room Copayment |
$100 (Credited toward inpatient admission if admitted within 24 hours). Emergency room copayment is payable in addition to applicable copayment, deductible and coinsurance. |
Biologically Based Mental Illness and Alcoholism
(Inpatient is subject to preapproval) |
Subject to deductible and coinsurance. |
|
Non-Biologically Based Mental Illness and Substance Abuse |
Maximum of 30 days inpatient care per calendar year.
One inpatient day may be exchanged for 2
outpatient visits; maximum 20 visits per calendar year. |
|
Blood/Blood Products/Processing |
Subject to deductible and coinsurance.. |
|
Diagnostic X-ray/Lab |
Subject to deductible and coinsurance. |
Durable Medical Equipment
(Subject to preapproval) |
Subject to deductible and coinsurance. |
Home Health Care and Hospice Care
(Subject to preapproval) |
Unlimited days; subject to deductible and coinsurance. |
|
Maternity |
$25 copayment for the initial visit;
$0 copayment thereafter. |
|
Prescription Drugs |
Subject to deductible and coinsurance. Coinsurance
paid for covered prescription drugs does not count
toward the maximum out of pocket. |
|
Preventive Care |
Office visit copayment per visit. |
Rehabilitation Centers
(Subject to preapproval) |
Subject to deductible and coinsurance. |
|
Speech, Physical (Subject to preapproval), Occupational and Cognitive Rehabilitation Therapies |
Subject to deductible and coinsurance.
Limited to 30 visits per calendar year. |
|
Therapeutic Manipulations |
Subject to deductible and coinsurance. Limited to
30 visits per calendar year and 2 modalities per visit. |
