ConnectiCare Passage Plan 1 (HMO-POS)

3.5 out of 5 stars
$0.00
Monthly Premium

ConnectiCare Passage Plan 1 (HMO-POS) is a HMO-POS plan offered by CONNECTICARE, INC.

Plan ID: H3528-010

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as ConnectiCare Passage Plan 1 (HMO-POS) - H3528-010 by CONNECTICARE, INC. as well as other Medicare Advantage plans available in your area.

$0.00
Monthly Premium

Connecticut Counties Served

FairfieldHartfordLitchfieldMiddlesexNew HavenNew LondonTollandWindham

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $200
Out of Pocket Max In-Network: $6750
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $2100
Primary Care Doctor Visit


Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit


Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$450 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Urgent Care

Urgent Care:
Copayment for Urgent Care $50

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0
Maximum Plan Benefit of $50,000
Emergency Room Visit

Emergency Care:
Copayment for Emergency Care $130

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0
Copayment for Worldwide Emergency Transportation $0
Maximum Plan Benefit of $50,000
Ambulance Transportation


Ground Ambulance:
Copayment for Ground Ambulance Services $295

Prior Authorization Required for Ground Ambulance Services

Air Ambulance:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

ConnectiCare Passage Plan 1 (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


Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Diabetes Supplies, Training, Nutrition Therapy and Monitoring


Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Durable Medical Equipment (DME)


Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 10% to 20%
Prior Authorization Required for Durable Medical Equipment
Minimum coinsurance applies to HIT drug component services provided in the home. Maximum coinsurance applies to HIT drug component services provided in all other locations and all other DME.
Diagnostic Tests, Lab and Radiology Services, and X-Rays


Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $25
Copayment for Medicare-covered Lab Services $0 to $15
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $295
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $45

Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home Health Care


Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental Health Inpatient Care


Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $2036
Prior Authorization Required for Psychiatric Hospital Services
Mental Health Outpatient Care


Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40

Prior Authorization Required for Outpatient Mental Health Care
Outpatient Services / Surgery


Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $395
Prior Authorization Required for Outpatient Hospital Services
Minimum amount for diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $295

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $250
Prior Authorization Required for Ambulatory Surgical Center Services
Minimum amount for diagnostic colonoscopies in an ASC setting. Maximum amount for all other services.
Outpatient Substance Abuse Care


Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter (OTC) Items


Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0

Combined Group Name: OTC with OTC Hearing Aids

Allowance Amount: $35.00 Every Month

Combined Benefit Groups: Over-the-Counter (OTC) Items; OTC Hearing Aids;

Mode of Delivery: Catalogue Purchase; Unused allowance does not carry over to the next month.
Podiatry Services


Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$209 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

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

Coverage Cost
Dental Care


Medicare Covered Preventive Dental:
Copayment for Office Visit $45

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0

  • Maximum 1 visit every six months

Copayment for Dental x-rays $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Other diagnostic services $0
Copayment for Prophylaxis $0

  • Maximum 1 visit every six months

Copayment for Fluoride treatment $0

  • Maximum 1 visit every six months

Copayment for Other preventive services $0

  • Maximum 1 visit every six months


Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Coinsurance for Restorative services 20% to 50%

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Endodontics 50%

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Periodontics 50%

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Prothodontics, removable 50%

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Maxillofacial surgery 50%

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Adjunctive general services $0
Maximum Plan Benefit of $2,000 every year
Deductible $100.00

Vision Benefits

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

Coverage Cost
Vision Benefits


Eye Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Eye Exams $0

  • Maximum 1 Routine Eye Exams every year


Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
Copayment for Eyeglass Lenses $0
Copayment for Eyeglass Frames $0
Maximum Plan Benefit of $200 every year

Hearing Benefits

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

Coverage Cost
Hearing Benefits


Hearing Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Hearing Exams $0

  • Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $45

  • Maximum 1 visit every year


Hearing Aids:
Copayment for Hearing Aids $0

  • Maximum 2 Hearing Aids every year

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


$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

Prescription Drug Costs and Coverage

The ConnectiCare Passage Plan 1 (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $200 (excludes Tiers 1 and 6) per year.

Coverage Cost
Coverage & Cost
Annual Drug Deductible $200 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $1.00
  • Standard mail order $1.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $200 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $2.00
  • Standard mail order $2.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $200 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $2.00
  • Standard mail order $2.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
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