Medical and Pharmacy Coverage
Horizons Diagnostics offers the following plans through Aetna. Please reference the Summary Plan Description for more details.
Insurance Carrier:
Aetna Medical Insurance
Medical Plan Number:
$3,000 / 100% Copay Plan
$5,000 / 100% Copay Plan $5,000 / 100% HDHP Plan
In-Network: Office Visit Copay - Primary Care
$30 Copay
$40 Copay
Deductible; then 100% Coinsurance
Office Visit Copay - Specialist Care
$60 Copay
$75 Copay
Deductible; then 100% Coinsurance
Urgent Care Copay
$60 Copay
$75 Copay
Deductible; then 100% Coinsurance
Emergency Room Care
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Preventative Visit Copay
$0
$0
$0
Diagnostic Testing & Blood Work
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Imaging
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Coinsurance
100%
100%
100%
Employee Deductible
$3,000
$5,000
$5,000
Family Deductible
$6,000
$10,000
$10,000
Employee Out-of-Pocket Max
$6,000 (includes deductible)
$8,000 (includes deductible)
$6,900 (includes deductible)
Family Out-of-Pocket Max
$12,000 (includes deductible)
$16,000 (includes deductible)
$13,800 (includes deductible)
Inpatient Hospital
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Outpatient Hospital or Facility
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Out-of-Network: Coinsurance
70%
70%
70%
Employee Deductible
$6,000
$10,000
$10,000
Family Deductible
$12,000
$20,000
$20,000
Employee Out-of-Pocket Max
$12,000
$20,000
$20,000
Family Out-of-Pocket Max
$24,000
$40,000
$40,000
Prescription Drugs: ( 30 Day Supply) Rx Deductible
$0
$0
Combined with Medical Deductible
Tier 1 - Generic
$20
$20
Deductible; then 100% Coinsurance
Tier 2 - Preferred
$45
$45
Deductible; then 100% Coinsurance
Tier 3 - Non-Preferred
$90
$90
Deductible; then 100% Coinsurance
Preferred - $250 Non-Preferred - $50
Preferred - $250 Non-Preferred - $50
Tier 4 - Specialty
Deductible; then 100% Coinsurance
Employee Monthly Deduction Employee Only
$532.18
$465.49 $930.98 $884.43
$411.67 $823.35 $782.18
Employee + Spouse
$1,064.36 $1,011.14 $1,702.98
Employee + Child(ren)
Family
$1,489.57
$1,317.37
7 Horizons Diagnostics, LLC. 2022 Enrollment Guide
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