LG Horizon PPO
Benefit-eligible employees and their eligible dependents can elect the PPO medical plan with 100% company-paid employee premiums.
“Benefit-Eligible” is defined as any employee who is regularly scheduled to work at least 30 hours per week (including Foreign Service Employees). Benefit-eligible employees can participate in all of LG’s benefits, unless otherwise specified.
An eligible dependent is defined as a:
- Legal spouse (same or opposite sex)
- Domestic partner (same or opposite sex)*
- Child(ren): biological, adopted, step, or foster child for whom you are the legal guardian; or child of your legal spouse/domestic partner (same or opposite sex) up to the child’s 26th birthday**.
If you have a child enrolled for coverage under the company’s benefit program with a disability that occurred before age 26, that child can remain enrolled for the duration of your coverage (even beyond age 26).
You must pay all the costs up to the deductible amount* before this plan begins to pay for certain covered services. Check your policy or plan document to see when the deductible applies.
The out-of-pocket maximum is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services.
Co-Payments & Co-Insurance
Co-payments are fixed dollar amounts (for example, $20) you pay for covered health care, usually when you receive the service. This plan encourages you to use participating providers by charging you lower deductibles, co-payments, and co-insurance amounts.
|In Network||Co-Payment Per Visit||Co-Insurance Per Visit|
|Primary Care Office Visit||$20||None|
|Diagnostic Test (Office Visits)||None||10%|
|Diagnostic Test (Hospital or Lab)||None||10%|
|Emergency Room Visits||$125||10%|
|In/Out Patient – Facility||None||10%|
|In/Out Patient – Physician||None||10%|
|Out-of-Network||Co-Payment Per Visit||Co-Insurance Per Visit|
|Primary Care Office Visit||None||40%|
|Diagnostic Test (Office Visits)||None||40%|
|Diagnostic Test (Hospital or Lab)||None||40%|
|Emergency Room Visits||$125||10%|
|In/Out Patient – Facility||None||40%|
|In/Out Patient – Physician||None||40%|
In-network and out-of-network co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your in-network co-insurance payment of 10% would be $100; your out-of-network co-insurance payment of 40% would be $400. This may change if you haven’t met your in-network or out-of-network deductibles.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference (this is called “balance billing”).
Employee and dependent medical coverage includes medically necessary prescription drugs and related supplies prescribed by a physician. Prescriptions are limited to a 30-day supply at retail pharmacies or a 90-day supply at a discounted price through Express Scripts.
If you’ve elected medical coverage, you receive prescription coverage automatically.
The Davis Vision Plan makes routine vision care affordable and convenient. Key features of the plan include:
- Annual eye examinations (beginning every January 1), covered in full after a $10 co-payment
- One-year eyeglass breakage warranty included on plan eyewear at no additional cost
- Contact lens coverage
- National network of credentialed preferred providers throughout the 50 states
- Out-of-network benefits
If you’ve elected medical coverage, you receive vision coverage automatically.
An example of lower costs and more benefits:
|Service||With Davis Vision||Without Davis Vision|
Please note that if you are enrolled in medical, you automatically receive vision and prescription benefits.