| Company/Plan Name |
Horizons Temporary Health Plan |
| Deductible |
|
| In-Network |
$2,000
Per Person, Per Term |
| Out-Network |
No separate Out-of-Network Deductible
|
| Maximum Family Deductible |
Three Per Family, Per Term |
| Coinsurance |
|
| In-Network |
70/30% to $10,000 |
| Out-Network |
No separate Out-of-Network CoInsurance |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$3,000 excluding Deductible |
| Out-Network |
No separate Out-of-Network out of pocket maximum (some charges may be higher than In-Network charges would be) |
| Maximum Benefit |
$1,000,000 Per Person, Per Term |
| Physician Office Visit |
|
| In-Network |
$20 CoPay
Applies to all eligible services provided as part of an office visit |
| Out-Network |
$20 CoPay
Applies to all eligible services provided as part of an office visit |
| Outpatient Lab & X-Ray |
|
| In-Network |
Deductible and CoInsurance apply |
| Out-Network |
Deductible and CoInsurance apply |
| Outpatient Preventive Care |
|
| In-Network |
Not Covered (unless mandated by state) |
| Out-Network |
Not Covered (unless mandated by state) |
| Prescription Drugs |
|
| Generic |
$15 CoPay, then 100% |
| Brand Name(formulary) |
Discount card supplied |
| Brand Name(Non-formulary) |
Discount card supplied |
| Outpatient Surgery |
|
| In-Network |
Deductible and CoInsurance apply |
| Out-Network |
Deductible and CoInsurance apply |
| Emergency Room |
|
| In-Network |
Deductible and CoInsurance apply ($200 maximum benefit for ground ambulance and $750 maximum air ambulance per trip) |
| Out-Network |
Deductible and CoInsurance apply ($200 maximum benefit for ground ambulance and $750 maximum air ambulance per trip) |
| Maternity Prenatal/Post Natal |
|
| In-Network |
Not Covered (complications due to pregnancy treated as any other illness) |
| Out-Network |
Not Covered (complications due to pregnancy treated as any other illness) |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
Deductible and CoInsurance apply |
| Out-Network |
Deductible and CoInsurance apply |
| Surgical |
|
| In-Network |
Deductible and CoInsurance apply |
| Out-Network |
Deductible and CoInsurance apply |
| Maternity |
|
| In-Network |
Not Covered (complications due to pregnancy treated as any other illness) |
| Out-Network |
Not Covered (complications due to pregnancy treated as any other illness) |
| Rate Guarantee |
|
| Optional Benefits |
|
| Supplemental Accident |
100% of the first $300 of eligible expenses incurred within 90 days of the accident are covered (optional). |
| 24 Hour Coverage |
|
| Other |
|
