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Horizon Medicare Advantage

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Comparison

STEP 1.
Choose your Medicare Advantage health plan...

	Horizon Medicare Blue Value (MA) Our HMO Plan	Horizon Medicare Blue Access (MA) Our POS Plan
	In Network	In Network	Out of Network
Choice of health care specialists	Must use network health care specialists	Must use network health care specialists	Your choice
Annual deductible	$0 $5,000 maximum (out-of-pocket limit)	$0 $5,000 maximum (out-of-pocket limit)	$900 $6,200 maximum (out-of-pocket limit)
Hospital coverage	$900 copay per stay. No additional copay if readmitted within 3 days	$75 copay per day for days 1-10. No additional copay if readmitted within 3 days after the last 10 days	65% coverage
Outpatient hospital services/surgery	$200 copay	$200 copay	65% coverage
Doctor office visits	$15 PCP copay, $35 specialist copay	$15 PCP copay, $35 specialist copay	65% coverage
Emergency care (worldwide)	100% coverage after $50 copay; copay waived if admitted within 24 hours	100% coverage after $50 copay; copay waived if admitted within 24 hours	100% coverage after $50 copay; copay waived if admitted within 24 hours
Skilled nursing facility	$0 days 1-5; $75 days 6-20; $100 days 21-100	$0 days 1-5 $50 days 6-20; $100 days 21-100	65% coverage
Home health care	$35 copay	$35 copay	65% coverage
Diagnostic tests, x-rays and lab services	$35¹ copay, depending on the services	$35¹ copay, depending on the services	65% coverage
Durable medical equipment	80% coverage	80% coverage	65% coverage
Routine physical exams	$15 copay for one routine exam per year	$15 copay for one routine exam per year	65% coverage
Preventive screenings available (Refer to Summary of Benefits)	Office visit copay may apply	Office visit copay may apply	65% coverage
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	100% coverage $15 copay for Hepatitis B Vaccine; Office visit copay may apply	Office visit copay may apply $15 copay for Hepatitis B Vaccine	65% coverage
Routine vision services	$15/$35 copay for annual routine eye exam, $100 reimbursement for eyewear every two years	$15/$35 copay for annual routine eye exam, $100 reimbursement for eyewear every two years	65% coverage
Dental services	Centurion; Negotiated fee (up to 30% discount on dental services)	Centurion; Negotiated fee (up to 30% discount on dental services)	Not covered
Hearing services²	$15/$35 copay for annual routine hearing exam, $750 hearing aid allowance every three years	$15/$35 copay for annual routine hearing exam, $750 hearing aid allowance every three years	$50 copay for annual routine hearing exam
Premium	$0 No health plan premium to pay and a $28 reduction on your Medicare Part B premium^3,4	$25.50³

Please note: This is only a partial listing of benefits. For a complete listing of plan benefits, please see the enclosed Summary of Benefits.

¹ All lab services must be performed by Labcorp or AtlantiCare. For services that LabCorp or AtlantiCare do not perform, the Specialist copay applies.
² Must use a HEARx facility or participating audiologists in counties where there are no HEARx facilities for in-network benefits.
³ You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicare or by another third party.
⁴ If you select the HMO plan with Rx, the $28 will be used toward the Part D benefit. If not, the $28 will be applied to your Medicare Part B premium.

STEP 2:
Choose your optional Medicare prescription drug plan.

Even if you don't take many prescription drugs now, your needs could change down the road. That's why Horizon Healthcare of New Jersey, Inc. offers you the option of adding Medicare prescription drug benefits to your plan. With three prescription drug benefit packages to choose from, you can customize your coverage to meet your needs.

Horizon Medicare Blue Rx Standard (Part of a MA-PD)

Deductible	$275
Annual drug costs up to $2,510	Generic	Preferred Brand	Brand	Specialty
	$5 copayment	$33 copayment	$55 copayment	25% coinsurance
Annual drug costs between $2,510 - $5,726.25 (up to a total of $4,050 out-of-pocket costs)	You pay 100%
Annual drug cost exceeds $5,726.25	You pay the greater of a $2.25 copayment for Generic ($5.60 copayment for Preferred Brand or Brand) or 5% coinsurance. For Specialty drugs, you pay 25% coinsurance.
Premium when you choose Horizon Medicare Blue Value with Rx Standard coverage		$7.50**
Premium when you choose Horizon Medicare Blue Access with Rx Standard coverage		$61.00**

Horizon Medicare Blue Rx Enhanced (Part of a MA-PD)

Deductible	$0
Annual drug costs up to $2,510	Generic	Preferred Brand	Brand	Specialty
	$5 copayment	$33 copayment	$55 copayment	33% coinsurance
Annual drug costs between $2,510 - $5,726.25 (up to a total of $4,050 out-of-pocket costs)	$5 copayment for Generics You pay 100% for all other prescriptions
Annual drug cost exceeds $5,726.25	You pay the greater of a $2.25 copayment for Generic ($5.60 copayment for Preferred Brand or Brand) or 5% coinsurance. For Specialty drugs, you pay 33% coinsurance.
Premium when you choose Horizon Medicare Blue Value with Rx Enhanced coverage		$31.60**
Premium when you choose Horizon Medicare Blue Access with Rx Enhanced coverage		$85.10**

Horizon Medicare Blue Rx Plus (Part of a MA-PD)

Deductible	$0
Annual drug costs up to $2,510	Generic	Preferred Brand	Brand	Specialty
	$0 copayment	$33 copayment	$55 copayment	33% coinsurance
Annual drug costs between $2,510 - $5,726.25 (up to a total of $4,050 out-of-pocket costs)	$0 copayment for generics You pay 100% for all other prescriptions
Annual drug cost exceeds $5,726.25	You pay the greater of a $2.25 copayment for Generic ($5.60 copayment for Preferred Brand or Brand) or 5% coinsurance. For Specialty drugs, you pay 33% coinsurance.
Premium when you choose Horizon Medicare Blue Value with Rx Plus coverage		$38.80**
Premium when you choose Horizon Medicare Blue Access with Rx Plus coverage		$92.30**

**You must continue to pay your Medicare Part B premium if not otherwise paid for by Medicaid or by another third party.

Last Updated: December 22, 2008