Medical and Pharmacy Coverage
Horizons Diagnostics offers the following plans through Aetna. Please reference the Summary Plan Description for more details.
Insurance Carrier: Medical Plan Number: In-Network: Office Visit Copay - Primary Care
Aetna Medical Insurance
$3,000 / 100% Copay Plan
$5,000 / 100% Copay Plan
$5,000 / 100% HDHP Plan
$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 Bi-Weekly Deduction Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Employee Only $97.93 $121.01 $71.76 $94.84 $60.77 $83.85 Employee + Spouse $377.24 $400.32 $315.68 $338.76 $266.01 $289.08 Employee + Child(ren) $358.38 $381.46 $299.90 $322.97 $252.70 $275.78 Family $603.59 $626.66 $505.09 $528.17 $425.61 $448.69
7 Horizons Diagnostics, LLC. 2022 Enrollment Guide
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