ConnectiCare Flex Plan 2 (HMO-POS)

ConnectiCare Flex Plan 2 (HMO-POS) H3528-015 Plan Details
4 out of 5 stars

ConnectiCare Flex Plan 2 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by CONNECTICARE, INC..
Plan ID: H3528-015.

$135.00
Monthly Premium

ConnectiCare Flex Plan 2 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by CONNECTICARE, INC..
Plan ID: H3528-015.

ConnectiCare Flex Plan 2 (HMO-POS) H3528-015 Plan Details
4 out of 5 stars

ConnectiCare Flex Plan 2 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by CONNECTICARE, INC..
Plan ID: H3528-015.

$135.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $300
Out of Pocket Max In-Network: $6000
Out-of-Network: 10000
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $15.00
POS (Out-of-Network):

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $50.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35.00
POS (Out-of-Network):

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $50.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$375.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent Care
Copayment for Urgent Care $35.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Maximum Plan Benefit of $50,000
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $300.00 (Ground Transportation Only)
Maximum Plan Benefit of $50,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $300.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
POS (Out-of-Network):

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

ConnectiCare Flex Plan 2 (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
POS (Out-of-Network):
Copayment for Medicare Covered Chiropractic Services $50.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 10% to 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Durable Medical Equipment 40%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $25.00
Copayment for Medicare-covered Lab Services $15.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $250.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $40.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Home Health 40%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1871.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 40%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $250.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $250.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $150.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 40%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
POS (Out-of-Network):
Copayment for Medicare Covered Podiatry Services $50.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$184.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
40% per day for days 1 to 100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:
Optional Rider Available for Preventive and Comprehensive Dental Benefits
Comprehensive Dental:
Copayment for Medicare-covered Benefits $35.00
Prior Authorization Required for Comprehensive Dental

POS (Out-of-Network):

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $50.00
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $35.00
Copayment for Routine Eye Exams $35.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35.00
Copayment for Routine Hearing Exams $35.00
  • Maximum 1 visit every year
POS (Out-of-Network):

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $50.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $50.00

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

    Prescription Drug Costs and Coverage

    The ConnectiCare Flex Plan 2 (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $300 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $2.00
    • Standard retail $9.00
    • Preferred mail order $0.00
    • Standard mail order $9.00
    Generic
    • Preferred retail $10.00
    • Standard retail $20.00
    • Preferred mail order $0.00
    • Standard mail order $20.00
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $4.00
    • Standard retail $18.00
    • Preferred mail order $0.00
    • Standard mail order $18.00
    Generic
    • Preferred retail $20.00
    • Standard retail $40.00
    • Preferred mail order $0.00
    • Standard mail order $40.00
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $27.00
    • Preferred mail order $0.00
    • Standard mail order $27.00
    Generic
    • Preferred retail $30.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00