, inc. & affiliates enrollment/change form -...

MEMBER(S): Date of Birth ConnectiCare Existing First Name/Middle Initial/Last Name Social Security Number (required) Sex (mm/dd/yy) Primary Care Provider Provider ID Number (optional) Patient

Employee

Spouse/Civil Union/Domestic Partner

Dependent 1

Dependent 2

Dependent 3

Are you currently using tobacco?Employee □Yes □No Spouse/Civil Union/Dom. Partner □Yes □No Dependent 1 □Yes □No Dependent 2 □Yes □No Dependent 3 □Yes □No

Race/Ethnicity (optional): This information is designed for the purpose of data collection and will not be used to determine eligibility, rating or claim payment.

Employee:

□ White □ Black/African American □ Hispanic/Latino □ Asian □ Amer. Indian/Alaska Native □ Native Hawaiian/Pacific Islander □ Other □ Unknown

Spouse/Civil Union/Domestic Partner:


Dependent 1:


Dependent 2:


Dependent 3:


□ Check if enrolling a disabled dependent age 26 or over and contact ConnectiCare to obtain a form for submitting proof of disability.

Other health care coverage: Will you have other health insurance in addition to this ConnectiCare plan, under a Group, HMO or Medicare plan? □ Yes □ No

If yes, name of person covered Employer

Insurance Co. Name and Address (Please attach a copy of your group medical insurance card.) Policy Number Medicare (Please attach a copy of your Medicare card.) □ Part A □Part B □Retired

Important: By signing here you are indicating that you have read and understand the information on the front and back of this form. This authorization is valid as long as you are enrolled in a ConnectiCare health plan, and for one year after enrollment in the plan ends. I certify that the information supplied in the form is correct. I agree to the consent on the reverse side of this form. �

Employee’s Signature Date

Enrollment /Change FormPlease print clearly, complete in full using ballpoint pen.

P.O. Box 4058, Farmington, CT 06034-4058www.connecticare.com 1-800-251-7722

EMPLOYEE: Complete the following two sections, sign at bottom and read information on reverse side.

Please check appropriate item: □ New Enrollment □ Terminate Enrollment □Add Dependent □Remove Dependent □Change Provider □ Change Division□COBRA Election □ Other (Name change, address change, etc. Indicate reason for change.)

Plan type: □ HMO □ High Deductible Health Plan (HDHP) □ Point-of-Service (POS) □ PPO □ FlexPOS □ Other Plan Name: (from Benefit Summary)

ConnectiCare, Inc. = HMO, HDHP, POS Benefit Plans and ConnectiCare Insurance Company, Inc. = PPO and FlexPOS Benefit Plans. MA employers cannot purchase CCI or CICI products.

Marital Status: □ Single □ Married/Civil Union □ Domestic Partner □ Legally Separated □ Separated □ Widowed □ Divorced

First Name Middle Name Last Name

Street Address City State ZIP Code

Home Telephone Number Work Telephone Number E-mail Address Primary Language (optional)

, Inc. & Affiliates

□ M□ F

□ M□ F

□ M□ F

□ M□ F

□ M□ F

Add

Dele

te

□ Yes□ No

□ Yes□ No

□ Yes□ No

□ Yes□ No

□ Yes□ No

/ / / /

�

/ /

EMPLOYER: Complete this section. Form cannot be processed without this information. COBRA □ Yes Length of coverage: Date of Hire (mm/dd/yy) Hours per week Coverage Effective Date (mm/dd/yy) Coverage End Date (mm/dd/yy)

□No □ 30 months □36 months □Other

Employee Work Location Group Name Plan Name Group Number/Division

Employer Signature Title Date

FOO1 07/14

ConnectiCare collects race/ethnicity data solely for the purposes of developing quality improvement programs, education, training, and marketing purposes. This data will not be used for determining eligibility, premium rate or claim payment.

I understand that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concern-ing any fact material thereto, commits a fraudulent insurance act, which is a crime punishable by penalties, imprisonment and restitution depending on applicable laws.

IMPORTANT: EMPLOYEE/MEMBER CONSENTOn my behalf and on behalf of my spouse and/or dependent(s), I hereby authorize any physician, hospital, provider, insurer, ConnectiCare Insurance Company, Inc. (CICI) or a CICI-affiliate, or other organization or person having records, data or information concerning health history or medical insurance for me or my family member(s), including but not limited to information concerning mental health, alcohol/ substance abuse or HIV or AIDS-related conditions, to transfer to any person or company such records, data or information as may be required for the purpose of providing treatment, paying claims, and performing other operations to administer my Benefit Plan. I understand that CICI’s privacy notice contains a more complete description of the purposes for which information about me and my dependent(s) may be used or disclosed and that I have a right to review the privacy notice prior to signing this consent. I understand that CICI may change such notice at any time but will provide me a copy of any amended notice. I understand that I have a right to request restrictions on how information about me and my dependent(s) may be used or disclosed to carry out the plan administration purposes and that CICI is not required to agree to the requested restrictions. I understand that this authorization is valid for the term of my and my dependents’ coverage under the Plan. I understand that I can revoke this authorization (but will be terminated from the Plan) at any time by giving written notice to CICI as long as CICI or others have not taken action relying on this authorization. I acknowledge that I have retained a copy of this authorization. I authorize payroll deduction, if any, for the coverage I have elected.

INSTRUCTIONS: DID YOU REMEMBER TO ...□Print clearly, complete all sections and sign at the bottom of page 1?□Clearly define (write in) the plan name you requested? (It is located at the top left of the Benefit Summary and is included in your enrollment package.)□Select your primary care physician and include the ConnectiCare Provider ID number? (Can be found in the Provider Directory or on Web site)□Attach a copy of your Medicare Card if you are Medicare-eligible?□Attach a copy of your group medical insurance card if you have other coverage?□Insert Social Security Number for each dependent?□Retain a copy of this form for your records?

DISCLOSURE OF MEDICAL LOSS RATIOThe medical loss ratio is defined as the ratio of incurred claims to earned premium for the prior calendar year for managed care plans issued in Connecticut. Claims shall be limited to medical expenses for services and supplies provided to enrollees and shall not include expenses for stop loss, reinsurance, enrollee educational programs, or other cost containment programs or features.

The Federal medical loss ratio has the same meaning as provided in and calculated in accordance with PPACA, PL 111-148, as amended from time to time, and regulations adopted thereunder.

• State Medical Loss Ratio for calendar year 2013 for ConnectiCare, Inc. (CCI): 84.8%• Federal Medical Loss Ratio for calendar year 2013 for ConnectiCare, Inc. (CCI): Individual 99.4% Small-Group 81.4% Large-Group 85.7%

• State Medical Loss Ratio for calendar year 2013 for ConnectiCare Insurance Company, Inc. (CICI): 78.9%• Federal Medical Loss Ratio for calendar year 2013 for ConnectiCare Insurance Company, Inc. (CICI): Individual 83.1% Small-Group 80.3% Large-Group 88.3%

HMO-OA-CAL-30-45-100-100D-11 HMO Open Access Calendar Year Plan BenefitSummaryThis is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations and exclusions,or consult with your benefits manager. All benefits described below are per member per Calendar year. A Referral from your Primary Care Provideris not required.Personalized for: Allied Community Svc

IN-NETWORKMEMBER PAYS

$6,350 per Member$12,700 per Family

Out-of-Pocket Maximum(Includes a combination of deductible,copayments and coinsurance for health andpharmacy services)

UnlimitedLifetime Maximum Benefit


PREVENTIVE SERVICES(Refer to "Prevention and Wellness" sectionfound at the end of this summary)

No Member costAdult Physical Exam(one exam per year when provided by a PCP)

No Member costInfant / Pediatric Physical Exam(frequency limits apply and the exam mustbe provided by a PCP)

No Member costGynecological Preventive Exam

No Member costPreventive Laboratory Services(Complete blood count and urinalysis, onetest per year)

$10 Copayment per visitBaseline Routine Mammography(ages 35 - 39)

No Member costAnnual Routine Mammography(age 40 or older)

$10 Copayment per visitBreast Ultrasound Screening

$10 Copayment per visitAnnual Routine Vision Exam(one exam per year when provided by anOptometrist or Ophthalmologist)


OUTPATIENT SERVICES

$30 Copayment per visitPrimary Care Provider Office Services(includes services for illness, injury, sickness,follow-up care and consultations)

CCI/HMO DEDUCTIBLE/BS LG (01/2015) Effective Date: 1/2015HMO-OA-CAL-30-238492HMO-OA-CAL-30-45-100-100D-11 57896697

1


OUTPATIENT SERVICES

$45 Copayment per visitSpecialist Office Services(includes services for illness, injury, sickness,follow-up care and consultations)

$30 Copayment per visitGynecological Office Services

No Member costMaternity Care Office Visits

Applicable office visit CopaymentAllergy Testingup to one visit every year

No Member costAllergy Injectionsup to 20 visits every year

No Member costLaboratory Services(includes services performed in a Hospitalor laboratory facility)

$10 Copayment per visitNon-Advanced Radiology(includes services performed in a Hospitalor radiology facility)

No Member costAdvanced Radiology(includes services for MRI, PET and CATscan, and nuclear cardiology performed ina Hospital or radiology facility)

$30 Copayment per visitOutpatient Rehabilitative Therapyup to 50 visits per year(includes services combined for physical,speech, and occupational therapy)

$45 Copayment per visitChiropractic Servicesup to 20 visits per year

No Member costHome Health Servicesup to 100 visits per year

$30 Copayment per visitRetail Clinic


EMERGENCY / URGENT CARE

$75 Copayment per visitWalk-In/Urgent Care Centers

$150 Copayment per visitEmergency Room(Copayment waived if admitted)

No Member costAmbulance Services


HOSPITAL SERVICES

$100 Copayment per day up to $500 per yearInpatient Hospital Services, IncludingRoom & Board

$100 Copayment per visitHospital Outpatient Surgical Facilities(includes services performed in a Hospitalfacility)


2


HOSPITAL SERVICES

$100 Copayment per visitAmbulatory Surgical Center(includes services performed in a stand-aloneambulatory facility)

No Member costSkilled Nursing and RehabilitationFacilitiesup to 90 days per year


MENTAL HEALTH SERVICES

$100 Copayment per day up to $500 per yearInpatient Mental Health Services(including inpatient acute and residentialprograms)

$100 Copayment per day up to $500 per yearInpatient Alcohol and SubstanceAbuse Treatment(including inpatient acute and residentialprograms)

$30 Copayment per visitOutpatient Mental Health, Alcohol andSubstance Abuse Treatment(including office visits and professionalservices provided in the home)

$10 Copayment per visitOutpatient Mental Health, Alcohol andSubstance Abuse Treatment(intensive outpatient treatment and partialhospitalization programs)


OTHER SERVICES

50%DurableMedical Equipment IncludingProsthetics and Disposable MedicalSupplies

20%Diabetic Equipment and Supplies


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PREVENTION AND WELLNESS

In-Network prevention and wellness services as defined by the United States Preventive Service Task Force (listed below) are exempt fromall member cost share (deductible, copayment and coinsurance) under the Patient Protection and Affordable Care Act (PPACA). Services thatare exempt from cost share must be identified by the specific codes. The codes your health care provider submits must match ConnectiCare’scoding list to be exempt from all cost share.1 Routine physical exam and appropriate screening and counseling for adults (including but not limited to depression, obesity and sexually

transmitted infections), one per year1 Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration

(including but not limited to depression, obesity and sexually transmitted infections)1 Preventive care and screenings for women supported by the Health Resources and Services Administration:

4 At least one well-woman preventive care visit annually to obtain the recommended preventive services4 Screening for diabetes during pregnancy, two per pregnancy4 Human Papillomavirus (HPV) testing, age 30 or older, one per year4 Counseling on sexually transmitted infections for all sexually active women, two per year4 Counseling and screening for human immune-deficiency virus (HIV) for all sexually active women4 Contraceptive methods approved by the Food and Drug administration, sterilization procedures and contraceptive patient education

and counseling4 Comprehensive lactation support, counseling, a manual breast pump, and breastfeeding supplies4 Screening and counseling for interpersonal and domestic violence for all women and adolescents

1 Bone density screenings, age 60 or older, one every 23 months1 Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, ages 50 - 75, one per year1 Routine mammography screening, age 40 or older, one per year1 Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC1 Outpatient laboratory services, one per year:

4 Cervical cancer and cervical dysplasia screening – pap smear4 Lipid cholesterol screening for adults and children at risk4 Fasting plasma glucose or hemoglobin A1c, age 18 and older for people at risk for diabetes4 Hematocrit and Hemoglobin, for children up to age 214 Lead screening, for children up to age 64 Tuberculin testing, for children up to age 214 Chlamydia, syphilis and gonorrhea screening for females all ages4 Human immunodeficiency virus screening – HIV testing (no limit)4 Hypothyroidism screening in newborns, under 3 months of age4 Screening for phenylketonuria (PKU) in newborns, under 3 months of age4 Screening for sickle cell disease in newborns, under 3 months of age4 Hepatitis B screening for adolescents and adults at risk4 Hepatitis C screening for adults at risk4 Lung Cancer Screening for adults ages 55 - 80 who have smoked

1 Routine vision screening up to age 21, one per year when services are rendered by a primary care provider1 Routine hearing screening up to age 21 when rendered by a primary care provider1 Dental caries prevention up to age 5 when rendered by a primary care provider1 Developmental, autism, and psychosocial/behavioral assessments up to age 21 when rendered by a primary care provider1 Dietary counseling for adults with hyperlipidemia or obesity1 Alcohol misuse screening and counseling1 Tobacco cessation interventions1 Screening for hepatitis B, iron deficient anemia, Rh (D) blood typing and asymptomatic bacteriuria in women who are pregnant1 Screening for abdominal aortic aneurysm in men age 65 – 75 who have ever smoked1 BRCA counseling and genetic screening for women at risk1 Physical therapy to prevent falls in adults ages 65 and olderGo to www.connecticare.com/preventive for more information on preventive care.


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Important Information

1 If you have questions regarding your plan, visit our website at www.connecticare.com or call us at (860) 674-5757 or 1-800-251-7722.1 For mental health, alcohol, and substance abuse services call 1-888-946-4658 to obtain pre-authorization.1 If you are a Massachusetts resident, please refer to your amendatory rider for Massachusetts mandated benefits for additional details of

your benefits.1 If you are a Massachusetts resident, this plan along with pharmacy services meets Massachusetts Minimum Creditable Coverage standard

for 2015.

Benefits are Pending Department of Insurance Approval


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Prescription Drug Copayment Plan Benefit SummaryThis is a brief summary of your prescription drug benefits. Refer to your Prescription Drug Rider for complete details on benefits, conditions,limitations and exclusions, or consult with your benefits manager. All benefits described below are per member per Calendar year.Personalized for: Allied Community Svc

PRESCRIPTION DRUGS

Covered prescription drugs through retail Participating Pharmacies or our mail order service. Generics are dispensed unless the providerwrites Dispense as Written on the prescription.

Your Plan includes the following: Mandatory Drug Substitution, Generic Substitution Program, Tiered Cost-Share Program, and VoluntaryMail Order Program.


RETAIL PHARMACY(up to a 30 day supply perprescription)

$6,350 EmployeeOut-of-Pocket Maximum$12,700 per Family(Includes a combination of deductible,

copayments and coinsurance for health andpharmacy services)

$5 CopaymentTier 1 drugs




MAIL ORDER PHARMACY(up to a 90 day supply perprescription)




Additional Information

1 Under this program covered prescription drugs and supplies are put into categories (i.e., tiers) to designate how they are to be covered andthe member's cost-share. The placement of a drug or supply into one of the tiers is determined by the ConnectiCare Pharmacy ServicesDepartment and approved by the ConnectiCare Pharmacy & Therapeutics Committee based on the drugs or supplies clinical effectivenessand cost, not on whether it is a generic drug or supply or brand name drug or supply.

1 Generic drugs can reduce your out-of-pocket prescription costs. Generics have the same active ingredients as brand name drugs, but usuallycost much less. So, ask your doctor or pharmacist if a generic alternative is available for your prescription. Also, remember to use aparticipating pharmacy. Most pharmacies in the United States participate in our network. To find one, visit our Web site atwww.connecticare.com or call our Member Services Department at 1-800-251-7722.

1 Certain prescription drugs and supplies require pre-authorization from us before they will be covered under the Prescription Drug Rider.You should visit our Web site at www.connecticare.com or call our Member Services Department at 1-800-251-7722 to find out if aprescription drug or supply requires pre-authorization.

1 Always remember to carry your ConnectiCare ID Card.1 If you are a Massachusetts resident, please refer to your amendatory rider for Massachusetts mandated benefits for additional details of

your benefits.



6

HMO-OA-CNT-30-45-1500HospDed-27 Open Access Contract Year Plan BenefitSummaryThis is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations and exclusions,or consult with your benefits manager. All benefits described below are per member per Contract year. A Referral from your Primary Care Provideris not required.Personalized for: Allied Community Svc


$1,500 per MemberBenefit Deductible$3,000 per Family(This Benefit Deductible is combined for ambulatory services (outpatient) and inpatientservices)

$5,000 per Member$10,000 per Family





No Member costAdult Physical Exam(one exam per year when provided by a PCP)

No Member costInfant / Pediatric Physical Exam(frequency limits apply and the exam mustbe provided by a PCP)

No Member costGynecological Preventive Exam

No Member costPreventive Laboratory Services(Complete blood count and urinalysis, onetest per year)

$10 Copayment per visitBaseline Routine Mammography(ages 35 - 39)

No Member costAnnual Routine Mammography(age 40 or older)

$10 Copayment per visitBreast Ultrasound Screening

$10 Copayment per visitAnnual Routine Vision Exam(one exam per year when provided by anOptometrist or Ophthalmologist)

CCI/HMO DEDUCTIBLE/BS LG (01/2015) Effective Date: 1/2015HMO-OA-CNT-30-238521HMO-OA-CNT-30-45-1500HospDed-27 58073151

1


OUTPATIENT SERVICES

$30 Copayment per visitPrimary Care Provider Office Services(includes services for illness, injury, sickness,follow-up care and consultations)

$45 Copayment per visitSpecialist Office Services(includes services for illness, injury, sickness,follow-up care and consultations)

$30 Copayment per visitGynecological Office Services


Applicable office visit CopaymentAllergy Testingup to one visit every year

No Member costAllergy Injectionsup to 20 visits every year

No Member costLaboratory Services(includes services performed in a Hospitalor laboratory facility)

$10 Copayment per visitNon-Advanced Radiology(includes services performed in a Hospitalor radiology facility)

$75 Copayment per visitAdvanced Radiologyup to five Copayments per year(includes services for MRI, PET and CATscan, and nuclear cardiology performed ina Hospital or radiology facility)

$30 Copayment per visitOutpatient Rehabilitative Therapyup to 40 visits per year(includes services combined for physical,speech, and occupational therapy)

$45 Copayment per visitChiropractic Servicesup to 20 visits per year

No Member costHome Health Servicesup to 100 visits per year

$30 Copayment per visitRetail Clinic



$75 Copayment per visitWalk-In/Urgent Care Centers

$150 Copayment per visitEmergency Room(Copayment waived if admitted)

No Member costAmbulance Services


2


HOSPITAL SERVICES

No Member cost after Benefit DeductibleInpatient Hospital Services, IncludingRoom & Board

No Member cost after Benefit DeductibleHospital Outpatient Surgical Facilities(includes services performed in a hospitalfacility)

No Member cost after Benefit DeductibleAmbulatory Surgical Center(includes services performed in a stand-aloneambulatory facility)

No Member costSkilled Nursing and RehabilitationFacilitiesup to 90 days per year



No Member cost after Benefit DeductibleInpatient Mental Health Services(including inpatient acute and residentialprograms)

No Member cost after Benefit DeductibleInpatient Alcohol and SubstanceAbuse Treatment(including inpatient acute and residentialprograms)

$30 Copayment per visitOutpatient Mental Health, Alcohol andSubstance Abuse Treatment(including office visits and professionalservices provided in the home)

No Member costOutpatient Mental Health, Alcohol andSubstance Abuse Treatment(intensive outpatient treatment and partialhospitalization programs)


OTHER SERVICES

50%DurableMedical Equipment IncludingProsthetics and Disposable MedicalSupplies

20%Diabetic Equipment and Supplies


3


In-Network prevention and wellness services as defined by the United States Preventive Service Task Force (listed below) are exempt fromall member cost share (deductible, copayment and coinsurance) under the Patient Protection and Affordable Care Act (PPACA). Services thatare exempt from cost share must be identified by the specific code(s). The codes your health care provider submits must match ConnectiCare’scoding list to be exempt from all cost share.

• Routine physical exam and appropriate screening and counseling for adults (including but not limited to depression, obesity and sexuallytransmitted infections) one per year• Preventive care and screening for infants, children and adolescents supported by the Health Resources and Services Administration(including but not limited to depression, obesity and sexually transmitted infections)• Preventive care and screenings for women supported by the Health Resources and Services Administration:

o At least one well-woman preventive care visit annually to obtain the recommended preventive serviceso Screening for diabetes during pregnancy, two per pregnancyo Human Papillomavirus (HPV) testing, age 30 or older, one per yearo Counseling on sexually transmitted infections for all sexually active women, two per yearo Counseling and screening for human immune-deficiency virus (HIV) for all sexually active womeno Contraceptive methods approved by the Food and Drug administration, sterilization procedures and contraceptive patient educationand counselingo Comprehensive lactation support, counseling, a manual breast pump, and breast feeding supplieso Screening and counseling for interpersonal and domestic violence for all women and adolescents

• Bone density screenings, age 60 or older, one every 23 months• Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, ages 50 - 75, one per year• Routine mammography screening, age 40 or older, one per year• Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC• Outpatient laboratory services, one per year:

o Cervical cancer and cervical dysplasia screening – pap smearo Lipid cholesterol screening for adults and children at risko Fasting plasma glucose or hemoglobin A1c, age 18 and older for people at risk for diabeteso Hematocrit and Hemoglobin, for children up to age 21o Lead screening, for children up to age 6o Tuberculin testing, for children up to age 21o Chlamydia, syphilis and gonorrhea screening for females all ageso Human immunodeficiency virus screening – HIV testing (no limit)o Hypothyroidism screening in newborns, under 3 months of ageo Screening for phenylketonuria (PKU) in newborns, under 3 months of ageo Screening for sickle cell disease in newborns, under 3 months of ageo Hepatitis B screening for adolescents and adults at risko Hepatitis C screening for adults at risko Lung Cancer screening for adults ages 55 - 80 who have smoked

• Routine vision screening up to age 21, one per year when services are rendered by a primary care provider• Routine hearing screening up to age 21 when rendered by a primary care provider• Dental caries prevention up to age 5 when rendered by a primary care provider• Developmental, autism, and psychosocial/behavioral assessments up to age 21 when rendered by a primary care provider• Dietary counseling for adults with hyperlipidemia or obesity• Alcohol misuse screening and counseling• Tobacco cessation interventions• Screening for hepatitis B, iron deficient anemia, Rh (D) blood typing and asymptomatic bacteriuria in women who are pregnant• Screening for abdominal aortic aneurysm in men age 65 – 75 who have ever smoked• BRCA counseling and genetic screening for women at risk• Physical therapy to prevent falls in adults ages 65 and older

Go to www.connecticare.com/preventive for more information on preventive care.


4




for 2015.



5

Prescription Drug Copayment Plan Benefit SummaryThis is a brief summary of your prescription drug benefits. Refer to your Prescription Drug Rider for complete details on benefits, conditions,limitations and exclusions, or consult with your benefits manager. All benefits described below are per member per Contract year.Personalized for: Allied Community Svc

PRESCRIPTION DRUGS





$5,000 EmployeeOut-of-Pocket Maximum$10,000 per Family(Includes a combination of deductible,













1 Certain prescription drugs and supplies require pre-authorization from us before they will be covered under the Prescription Drug Rider.You should visit our Web site at www.connecticare.com or call our Member Services Department at 1-800-251-7722 to find out if aprescription drug or supply requires pre-authorization.


your benefits.



6

POS-OA-CNT-30POV-U1000-20COINS-03 Point-Of-Service Open Access ContractYear Plan Benefit SummaryThis is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations and exclusions,or consult with your benefits manager. All benefits described below are per member per Contract year. A referral from your primary care provideris not required.Personalized for: Allied Community Svc

OUT-OF-NETWORKMEMBER PAYS


$5,000 per Individual$1,000 per IndividualContract Year Plan Deductible$10,000 per Family$2,000 per Family

$15,000 per Individual$3,000 per IndividualOut-of-Pocket Maximum$30,000 per Family$6,000 per Family(Includes a combination of deductible,

copayments and coinsurance for healthand pharmacy services)

Plan will reimburse the coinsurancepercentage of the Maximum AllowableAmount.

Not ApplicableOut-of-Network Reimbursement

UnlimitedUnlimitedLifetime Maximum Benefit



PREVENTIVE SERVICES(Refer to "Prevention and Wellness"section found at the end of this summary)

20% after Plan DeductibleNo Member cost (Plan Deductible waived)Adult Physical Exam(one exam per year when provided by aPCP)

20% after Plan DeductibleNo Member costInfant / Pediatric Physical Exam(Plan Deductible waived)(frequency limits apply and the exammust

be provided by a PCP)

20% after Plan DeductibleNo Member costGynecological Preventive Exam(Plan Deductible waived)

20% after Plan Deductible20%Preventive Laboratory Services(Plan Deductible waived)(Complete blood count and urinalysis, one

test per year)

20% after Plan Deductible20% after Plan DeductibleBaseline Routine Mammography(ages 35 - 39)

20% after Plan DeductibleNo Member costAnnual Routine Mammography(Plan Deductible waived)(age 40 or older)

20% after Plan Deductible20% after Plan DeductibleBreast Ultrasound Screening

CICI/POS/Copay-Coins/BS LG (01/2015) Effective Date: 1/2015POS-OA-CNT-30P238523POS-OA-CNT-30POV-U1000-20COINS-03 58073450

1



PREVENTIVE SERVICES(Refer to "Prevention and Wellness"section found at the end of this summary)

20% after Plan Deductible20% (Plan Deductible waived)Annual Routine Vision Exam(one exam per year when provided by anOptometrist or Ophthalmologist)



OUTPATIENT SERVICES

20% after Plan Deductible$30 Copayment per visit (Plan Deductiblewaived)

Primary Care Provider OfficeServices(includes services for illness, injury,sickness, follow-up care and consultations)

20% after Plan Deductible20% after Plan DeductibleSpecialist Office Services(includes services for illness, injury,sickness, follow-up care and consultations)

20% after Plan Deductible20% after Plan DeductibleGynecological Office Services

20% after Plan DeductibleNo Member costMaternity Care Office Visits

20% after Plan Deductible20% after Plan DeductibleAllergy Testingup to one visit every year

20% after Plan Deductible20% after Plan DeductibleAllergy Injectionsup to 20 visits every year

20% after Plan Deductible20% after Plan DeductibleLaboratory Services(includes services performed in a Hospitalor laboratory facility)

20% after Plan Deductible20% after Plan DeductibleNon-Advanced Radiology(includes services performed in a Hospitalor radiology facility)

20% after Plan Deductible20% after Plan DeductibleAdvanced Radiology

(includes services forMRI, PET and CATscan and nuclear cardiology performed ina Hospital or radiology facility)

20% after Plan Deductible20% after Plan DeductibleOutpatient Rehabilitative Therapyup to 40 visits per year(includes services combined for physical,speech, and occupational therapy)

20% after Plan Deductible20% after Plan DeductibleChiropractic Servicesup to 20 visits per year


Retail Clinic




Same as In-Network Benefit20% after Plan DeductibleWalk-In/Urgent Care Centers

Same as In-Network Benefit20% after Plan DeductibleEmergency Room


2




Same as In-Network Benefit20% after Plan DeductibleAmbulance Services



HOSPITAL SERVICES

20% after Plan Deductible20% after Plan DeductibleInpatient Hospital Services,Including Room & Board(includes facility and provider services)

20% after Plan Deductible20% after Plan DeductibleHospital Outpatient SurgicalFacilities(includes services performed in a Hospitalfacility)

20% after Plan Deductible20% after Plan DeductibleAmbulatory Surgical Center(includes services performed in astand-alone ambulatory facility)

20% after Plan Deductible20% after Plan DeductibleSkilled Nursing and RehabilitationFacilitiesup to 90 days per year




20% after Plan Deductible20% after Plan DeductibleInpatient Mental Health Services(including inpatient acute and residentialprograms)

20% after Plan Deductible20% after Plan DeductibleInpatient Alcohol and SubstanceAbuse Treatment(including inpatient acute and residentialprograms)


Outpatient Mental Health, Alcoholand Substance Abuse Treatment(including office visits and professionalservices provided in the home)


Outpatient Mental Health, Alcoholand Substance Abuse Treatment(intensive outpatient treatment and partialhospitalization programs)



OTHER SERVICES

20% after Plan Deductible20% after Plan DeductibleDurable Medical Equipment,Including Prosthetics andDisposable Medical Supplies

20% after Plan Deductible20% after Plan DeductibleDiabetic Equipment and Supplies

20% (Plan Deductible waived)20% (Plan Deductible waived)Home Health Servicesup to 100 visits per year(If you are a Massachusetts resident, thevisit maximum is waived as mandated byState Law)


3


In-Network prevention and wellness services as defined by the United States Preventive Service Task Force (listed below) are exempt fromall member cost share (deductible, copayment and coinsurance) under the Patient Protection and Affordable Care Act (PPACA). Services thatare exempt from cost share must be identified by the specific code(s). The codes your health care provider submits must match ConnectiCare’scoding list to be exempt from all cost share.• Routine physical exam and appropriate screening and counseling for adults (including but not limited to depression, obesity and sexuallytransmitted infections) one per year• Preventive care and screening for infants, children and adolescents supported by the Health Resources and Services Administration (includingbut not limited to depression, obesity and sexually transmitted infections)• Preventive care and screenings for women supported by the Health Resources and Services Administration:o At least one well-woman preventive care visit annually to obtain the recommended preventive serviceso Screening for diabetes during pregnancy, two per pregnancyo Human Papillomavirus (HPV) testing, age 30 or older, one per yearo Counseling on sexually transmitted infections for all sexually active women, two per yearo Counseling and screening for human immune-deficiency virus (HIV) for all sexually active womeno Contraceptive methods approved by the Food and Drug administration, sterilization procedures and contraceptive patient education andcounselingo Comprehensive lactation support, counseling, a manual breast pump, and breast feeding supplieso Screening and counseling for interpersonal and domestic violence for all women and adolescent• Bone density screenings, age 60 or older, one every 23 months• Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, ages 50 - 75, one per year• Routine mammography screening, age 40 or older, one per year• Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC• Outpatient laboratory services, one per year:o Cervical cancer and cervical dysplasia screening – pap smearo Lipid cholesterol screening for adults and children at risko Fasting plasma glucose or hemoglobin A1c, age 18 and older for people at risk for diabeteso Hematocrit and Hemoglobin, for children up to age 21.o Lead screening, for children up to age 6o Tuberculin testing, for children up to age 21o Chlamydia, syphilis and gonorrhea screening for females all ageso Human immunodeficiency virus screening – HIV testing (no limit)o Hypothyroidism screening in newborns, under 3 months of ageo Screening for phenylketonuria (PKU) in newborns, under 3 months of ageo Screening for sickle cell disease in newborns, under 3 months of ageo Hepatitis B screening for adolescents and adults at risko Hepatitis C screening for adults at risko Lung Cancer screening for adults ages 55 - 80 who have smoked• Routine vision screening up to age 21, one per year when services are rendered by a primary care provider• Routine hearing screening up to age 21 when rendered by a primary care provider• Dental caries prevention up to age 5 when rendered by a primary care provider• Developmental, autism, and psychosocial/behavioral assessments up to age 21 when rendered by a primary care provider• Dietary counseling for adults with hyperlipidemia or obesity• Alcohol misuse screening and counseling• Tobacco cessation interventions• Screening for hepatitis B, iron deficient anemia, Rh (D) blood typing and asymptomatic bacteriuria in women who are pregnant• Screening for abdominal aortic aneurysm in men age 65 – 75 who have ever smoked• BRCA counseling and genetic screening for women at risk• Physical therapy to prevent falls in adults ages 65 and olderGo to www.connecticare.com/preventive for more information on preventive care.


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1 If you have questions regarding your plan, visit our website at www.connecticare.com or call us at (860) 674-5757 or 1-800-251-7722.1 Many services require that you obtain our pre-certification or pre-authorization prior to obtaining care prescribed or rendered by

non-participating providers or a benefit reduction will apply. For mental health, alcohol, and substance abuse services call 1-888-946-4658to obtain pre-authorization.

1 Out-of-Network reimbursement is based on the maximum allowable amount. Members are responsible to pay any charges in excess of thisamount. Please refer to your ConnectiCare Inc. Membership Agreement for more information.

1 If you are a Massachusetts resident, please refer to your amendatory rider for Massachusetts mandated benefits for additional details ofyour benefits.

1 If you are a Massachusetts resident, this plan along with pharmacy services meets Massachusetts Minimum Creditable Coverage Standardsfor 2015.



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Prescription Drug Copayment Plan Benefit SummaryThis is a brief summary of your prescription drug benefits. Refer to your prescription drug rider for complete details on benefits, conditions,limitations and exclusions, or consult with your benefits manager. All benefits described below are per member per Contract year.Personalized for: Allied Community Svc

PRESCRIPTION DRUGS





$15,000 per Member$3,000 per MemberOut-of-Pocket Maximum$30,000 per Family$6,000 per Family(Includes a combination of deductible,

copayments and coinsurance for healthand pharmacy services)




50%$5 CopaymentTier 1 drugs










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1 Under this program covered prescription drugs and supplies are put into categories (i.e., tiers) to designate how they are to be covered andthe member's cost-share. The placement of a drug or supply into one of the tiers is determined by the ConnectiCare Pharmacy ServicesDepartment and approved by the ConnectiCare Pharmacy & Therapeutics Committee based on the drug's or supply's clinical effectivenessand cost, not on whether it is a generic drug or supply or brand name drug or supply.


1 Certain prescription drugs and supplies require pre-authorization from us before they will be covered under the prescription drug rider.You should visit our Web site at www.connecticare.com or call our Member Service Department at 1-800-251-7722 to find out if aprescription drug or supply requires pre-authorization.


your benefits.



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HMO-OA-CNT-HSA-2000I/4000F-34 Contract Year Benefit SummaryHMO Open Access High Deductible Health Plan (HDHP) for use with a Health Savings Account (HSA)This is a brief summary of benefits. Refer to yourMembership Agreement for complete details on all benefits, conditions, limitations and exclusions, orconsult with your benefits manager. All benefits described below are per member per Contract year. A referral from your primary care provideris not required.

The individual deductible applies if you have coverage only for yourself and not for any dependents. The family deductible applies if you havecoverage for yourself and one or more eligible dependents. In addition, if you have family coverage, any applicable copayment, coinsurance orcost share maximums will apply until the total is met for the family, without regard to how much any one family member has met.Personalized for: Allied Community Svc


$2,000 IndividualContract Year Plan Deductible$4,000 Family(Deductible is combined for health services

and prescription drugs)

$4,000 Individual$8,000 Family





No Member cost (Plan Deductible waived)Adult Annual Physical Exam(one exam per year when provided by a PCP)

No Member costInfant / Pediatric Physical Exam(Plan Deductible waived)(frequency limits apply and the exam must

be provided by a PCP)

No Member costGynecological Preventive Exam(Plan Deductible waived)

No Member costPreventive Laboratory Services(Plan Deductible waived)(Complete blood count and urinalysis, one

test per year)

No Member cost after Plan DeductibleBaseline Routine Mammography(ages 35 - 39)

No Member costAnnual Routine Mammography(Plan Deductible waived)(age 40 or older)

No Member cost after Plan DeductibleBreast Ultrasound Screening

No Member cost (Plan Deductible waived)Annual Routine Vision Exam(one exam per year when provided by anOptometrist or Ophthalmologist)

CCI/HMO OA HDHP/BS LG (01/2015) Effective Date: 1/2015HMO-OA-CNT-HSA238498HMO-OA-CNT-HSA-2000I/4000F-34 58073289

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OUTPATIENT SERVICES

No Member cost after Plan DeductiblePrimary Care Provider Office Services(includes services for illness, injury, sickness,follow-up care and consultations)

No Member cost after Plan DeductibleSpecialist Office Services(includes services for illness, injury, sickness,follow-up care and consultations)

No Member cost after Plan DeductibleGynecological Office Services


No Member cost after Plan DeductibleAllergy Testingup to one visit per year

No Member cost after Plan DeductibleAllergy Injections

No Member cost after Plan DeductibleLaboratory Services(includes services performed in a Hospitalor laboratory facility)

No Member cost after Plan DeductibleNon-Advanced Radiology(includes services performed in a Hospitalor radiology facility)

No Member cost after Plan DeductibleAdvanced Radiology(includes services for MRI, PET and CATscan, and nuclear cardiology performed ina Hospital or radiology facility)

No Member cost after Plan DeductibleOutpatient Rehabilitative Therapyup to 20 visits per year(includes services combined for physical,speech, and occupational therapy)

No Member cost after Plan DeductibleChiropractic Servicesup to 10 visits per year

No Member cost after Plan DeductibleRetail Clinic



No Member cost after Plan DeductibleWalk-In/Urgent Care Centers

No Member cost after Plan DeductibleEmergency Room

No Member cost after Plan DeductibleAmbulance Services


HOSPITAL SERVICES

No Member cost after Plan DeductibleInpatient Hospital Services, IncludingRoom & Board

No Member cost after Plan DeductibleHospital Outpatient Surgical Facilities(includes services performed in a Hospitalfacility)


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HOSPITAL SERVICES

No Member cost after Plan DeductibleAmbulatory Surgical Center(includes services performed in a stand-aloneambulatory facility)

No Member cost after Plan DeductibleSkilled Nursing and RehabilitationFacilitiesup to 90 days per year



No Member cost after Plan DeductibleInpatient Mental Health Services(including inpatient acute and residentialprograms)

No Member cost after Plan DeductibleInpatient Alcohol and SubstanceAbuse Treatment(including inpatient acute and residentialprograms)

No Member cost after Plan DeductibleOutpatient Mental Health, Alcohol andSubstance Abuse Treatment(including office visits and professionalservices provided in the home)

No Member cost after Plan DeductibleOutpatient Mental Health, Alcohol andSubstance Abuse Treatment(intensive outpatient treatment and partialhospitalization programs)


OTHER SERVICES

No Member cost after Plan DeductibleDurableMedical Equipment IncludingProsthetics and Disposable MedicalSupplies

No Member cost after Plan DeductibleDiabetic Equipment and Supplies

No Member cost after Plan DeductibleHome Health Servicesup to 100 visits per year


3


In-Network prevention and wellness services as defined by the United States Preventive Service Task Force (listed below) are exempt fromall member cost share (deductible, copayment and coinsurance) under the Patient Protection and Affordable Care Act (PPACA). Services thatare exempt from cost share must be identified by the specific code(s). The code(s) your health care provider submits must match ConnectiCare’scoding list to be exempt from all cost share.1 Routine physical exam and appropriate screening and counseling for adults (including but not limited to depression, obesity and sexually

transmitted infections), one per year1 Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration

(including but not limited to depression, obesity and sexually transmitted infections)1 Preventive care and screenings for women supported by the Health Resources and Services Administration:

4 At least one well-woman preventive care visit annually to obtain the recommended preventive services4 Screening for diabetes during pregnancy, two per pregnancy4 Human Papillomavirus (HPV) testing, age 30 or older, one per year4 Counseling on sexually transmitted infections for all sexually active women, two per year4 Counseling and screening for human immune-deficiency virus (HIV) for all sexually active women4 Contraceptive methods approved by the Food and Drug administration, sterilization procedures and contraceptive patient education

and counseling4 Comprehensive lactation support, counseling, a manual breast pump, and breastfeeding supplies4 Screening and counseling for interpersonal and domestic violence for all women and adolescents

1 Bone density screenings, age 60 or older, one every 23 months1 Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, ages 50 - 75, one per year1 Routine mammography screening, age 40 or older, one per year1 Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC1 Outpatient laboratory services, one per year:

4 Cervical cancer and cervical dysplasia screening – pap smear4 Lipid cholesterol screening for adults and children at risk4 Fasting plasma glucose or hemoglobin A1c, age 18 and older for people at risk for diabetes4 Hematocrit and Hemoglobin, for children up to age 21.4 Lead screening, for children up to age 64 Tuberculin testing, for children up to age 214 Chlamydia, syphilis and gonorrhea screening for females all ages4 Human immunodeficiency virus screening – HIV testing (no limit)4 Hypothyroidism screening in newborns, under 3 months of age4 Screening for phenylketonuria (PKU) in newborns, under 3 months of age4 Screening for sickle cell disease in newborns, under 3 months of age4 Hepatitis B screening for adolescents and adults at risk4 Hepatitis C screening for adults at risk4 Lung Cancer Screening for adults ages 55-80 who have smoked

1 Routine vision screening up to age 21, one per year when services are rendered by a primary care provider1 Routine hearing screening up to age 21 when rendered by a primary care provider1 Dental caries prevention up to age 5 when rendered by a primary care provider1 Developmental, autism, and psychosocial/behavioral assessments up to age 21 when rendered by a primary care provider.1 Dietary counseling for adults with hyperlipidemia or obesity1 Alcohol misuse screening and counseling1 Tobacco cessation interventions1 Screening for hepatitis B, iron deficient anemia, Rh (D) blood typing and asymptomatic bacteriuria in women who are pregnant.1 Screening for abdominal aortic aneurysm in men age 65 – 75 who have ever smoked1 BRCA counseling and genetic screening for women at risk1 Physical therapy to prevent falls in adults ages 65 and olderGo to www.connecticare.com/preventive for more information on preventive care.


4




for 2015.



5

Prescription Drug Copayment Plan - HMOOpen Access High Deductible Health Plan(HDHP) for Use with Health Savings Account (HSA) Benefit SummaryThis is a brief summary of your prescription drug benefits. Refer to your Prescription Drug Rider for complete details on benefits, conditions,limitations and exclusions, or consult with your benefits manager. All benefits described below are per member per Contract year.Personalized for: Allied Community Svc

PRESCRIPTION DRUGS



IN-NETWORK

$2,000 IndividualContract Year Plan Deductible$4,000 Family

The Contract Year Deductible can be reached by any combination of covered Health Servicesor covered prescription drug services.

If you have Family coverage, then covered Health Services and covered prescription drugswill be applied to the Family Plan Deductible until the total amount is met without regard towhich family member uses the benefits.

$4,000 IndividualOut-of-Pocket Maximum$8,000 Family(Includes a combination of deductible,


MEMBER PAYSRETAIL PHARMACY(up to a 30 day supply perprescription)

$5 Copayment after Plan DeductibleTier 1 drugs



MEMBER PAYSMAIL ORDER PHARMACY(up to a 90 day supply perprescription)

$10 Copayment after Plan Deductible uTier 1 drugs




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1 Amounts paid by members because they must pay a price difference for a brand name drug do not count towards meeting any deductible,coinsurance, copayment, or pharmacy coinsurance maximum.

1 Certain prescription drugs and supplies require pre-authorization from us before they will be covered under the prescription drug rider.You should visit our Web site at www.connecticare.com or call our Member Services Department at 1-800-251-7722 to find out if aprescription drug or supply requires pre-authorization.


your benefits.



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