2020 connecticare preferred portfolio plans · ny preferred portfolio plans – you have options...

2020 ConnectiCare Preferred Portfolio Plans

311-800-723-2986

Welcome to ConnectiCare

This guide includes information on the benefits and services that come with our preferred portfolio plans for employers with more than 50 employees. We’re pleased to offer a wide range of options, including:

Powered by people for a healthier youChoose ConnectiCare and you’ll discover we’re more than just a health insurance company. We’re people driven to support the health of your business and your employees every step of the way.

If you have questions about our preferred portfolio plans, contact your broker or your ConnectiCare sales representative.

We’re here to help.

Thank you for considering ConnectiCare.

Plans with national and regional networks to meet the needs of your workforce

Plans with deductibles waived for services like doctor office visits, urgent care, and mental health office visits

Opportunity to add a ConnectiCare dental plan to your employee benefits

Plans with integrated health savings accounts (HSAs) administered through HealthEquity

Did you know?

Member calls are answered right here in the state – and our call center has won international recognition for service quality.

Your employees can meet with us in person and attend events at ConnectiCare centers around Connecticut.

We’re part of EmblemHealth, one of the nation’s largest non-profit health insurers.

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Benefits and savings your employees need

Preventive care coverage for services like annual checkups, screenings, flu shots, and other vaccinations

Prescription drug coverage, with low copays for tier 1, 2 and 3 drugs

Mental health and substance abuse coverage

Emergency and urgent care coverage anywhere in the world1

Telemedicine – your employees can call or use the mobile app 24/7 to visit a doctor whether they’re home, at work, or on the road.

With some plans, $0 copays for primary care visits at Sanitas Medical Centers in Bridgeport, Hartford, and Newington2

Helping make health care dollars go further

Network discounts for care Your employees benefit from ConnectiCare-negotiated rates for services of doctors, hospitals and other facilities. This is important when they share the costs of their care. Plus, members can sign into connecticare.com and use the Treatment Cost Calculator to get personalized estimates of their costs and what their plan will pay for many tests and procedures.

Savings on prescriptions Your employees can get 90-day supplies of drugs they take to stay well with free home delivery. Besides the convenience, home delivery helps members stay on track with taking medicines they need to manage health conditions and stay healthy.

Discounts on everyday items and major purchases Gym memberships, glasses and contacts, acupuncture and massage, vacations and major purchases. Discounts on these products and services – and many more – are available to ConnectiCare members. Visit connecticare.com/discountprograms to see all discounts.

HSAs through HealthEquity Integrate your HSA-compatible plan with HSAs from HealthEquity, one of the nation's largest administrators of tax-advantaged health accounts. Help your employees save money tax-free to help pay for qualified health expenses. And, give them the freedom to save for qualified health care expenses they have in the future – even in retirement.

All preferred portfolio plans include the benefits that help your employees (and their families) stay healthy.

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Helping your employees get the care they needExtra support in time of need ConnectiCare nurses, social workers, pharmacists, and health care guides help our members when they’re sick or don’t know where to turn.

Personalized health tips Your employees can take a short, online health assessment, presented by our affiliate company, WellSpark Health, and immediately get personalized tips on how to live healthier and lower potential health risks.

Collaborations with health care providers ConnectiCare has strong, longstanding relationships with the doctors and hospitals in our network. Many of those have committed to collaborative monitoring and management. These collaborations can help drive better outcomes for our members*, including:

5%

Acute hospital days

decrease7%

Emergency room visits

decrease20%

Colorectal cancer screenings

increase

Wellness visits

39%increase 14%

Overall costs

decrease*ConnectiCare internal analysis of member and provider collaborations vs. members not in provider collaborations for 2018.

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And promoting better health in other waysDental health is whole body health Employees value dental coverage. And good dental hygiene can help lead to earlier identification and treatment of some physical conditions and diseases.

It’s easy to add a ConnectiCare dental plan. You have a choice of plans with preventive and comprehensive services. There’s a large network of dental providers, plus coverage for out-of-network services.

Talk to your broker or to your ConnectiCare sales representative to get a quote for a ConnectiCare dental plan.

Encouraging your employees to use their plans There are a number of ways we help your employees get the most out of their plans:

Connecticare.com lets employees look up benefits, find in-network doctors, estimate the cost of a treatment or test, and more.

Our monthly email newsletter and social media accounts remind employees and covered family members about ways to stay healthy and ConnectiCare programs and services.

Those who live or work near ConnectiCare centers can get in-person help and take advantage of center fitness and educational programs.

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STATEWIDE COVERAGE

Thousands of doctors and every hospital in Connecticut

REGIONAL COVERAGE

Robust regional network through ConnectiCare and

EmblemHealth Prime networks

NATIONAL COVERAGE

Through a recognized third-party network

administrator

CT

MA

RINY

Preferred portfolio plans – you have options Here’s some information to help you decide which ConnectiCare plan or plans suit your employees’ needs best. Plans fall into one of three categories – Choice, FlexPOS, or Passage.

CHOICE PLANS Choice plans let your employees see any of the doctors, hospitals, and other health care providers in our regional network throughout Connecticut and parts of Massachusetts, Rhode Island, and New York. And, they can see specialists without referrals.

FLEXPOS PLANSFlexPOS plans include a national network, providing the most flexibility for your employees. And, they can see specialists without referrals. PASSAGE PLANS With a Passage plan, your employees must choose a primary care provider (PCP) from those who accept the plan (many, but not all, do). And, they will need their PCP to refer them to some types of specialists.

We've got your employees coveredWe understand what matters to your employees – seeing the doctors and visiting the hospitals they choose. Our networks give them lots of choices.

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More to know about your optionsHere are a few more things to keep in mind as you review the plans on the following pages.

In- and out-of-network benefits

Plans with "HMO" (for "health maintenance organization") or "EPO" (for "exclusive provider organization") in their names pay only when employees get services from in-network doctors, hospitals, and other health care providers.

Plans with "POS" (for "point of service") in their names cover some out-of-network services, although employees will generally pay more.

HSA-compatible plansEach HSA-compatible plan has "(E)" or "(A)" after its name:

(E) means that the plan has an “embedded” deductible. With an embedded deductible, when any one family member has health care expenses equal to the individual deductible, ConnectiCare begins to pay for covered services for that one family member.

(A) means that the plan has an “aggregate” deductible for all family members together. With an aggregate deductible, ConnectiCare does not begin to pay for covered services until the full family deductible is met.

At ConnectiCare, when we see our members, we see ourselves.

And, we treat our members like family and neighbors.

Your employees will enjoy superior customer service

from our staff, who take time to explain benefits

and answer questions. That happens whether your

employees call us or take advantage of in-person

service at a ConnectiCare center.

371-800-723-2986

Passage HMO plansPlan name/Metal level

Contract-year Contract-year

Passage HMO PCP Copay

$4000/$8000Ded CNT 06

Passage HMO PCP HSA

$2000/$4000Ded CNT 06 (A)*

PLAN/MEDICAL DEDUCTIBLE

Deductible (individual/family) $4,000/$8,000 $2,000/$4,000**

Maximum out-of-pocket limit (individual/family) $7,000/$14,000 $4,000/$8,000

IN-NETWORK MEDICAL BENEFITS

Preventive care/screenings/immunizations $0 $0

Primary care provider (PCP) servicesAt a Sanitas Medical Center: $0

For all other primary care: $30 copay (deductible waived)

$0 after deductible

Specialist services (Some specialist services require a PCP’s referral)

$45 copay (deductible waived) $0 after deductible

Mental health and substance abuse office visits $30 copay (deductible waived) $0 after deductible

Routine vision $45 copay (deductible waived) $0 (deductible waived)

Walk-in/urgent care center $75 copay (deductible waived) $0 after deductible

Worldwide emergency coverage*** $0 after deductible $0 after deductible

Hospital - inpatient treatment $0 after deductible $0 after deductible

Hospital - outpatient treatment $0 after deductible $0 after deductible

Outpatient surgery in freestanding locations $0 after deductible $0 after deductible

Lab services $0 after deductible $0 after deductible

X-rays $0 after deductible $0 after deductible

Advanced imaging (CT scans & MRI) $0 after deductible $0 after deductible

OUT-OF-NETWORK MEDICAL BENEFITS

Deductible (individual/family) N/A N/A

Coinsurance N/A N/A

Maximum out-of-pocket limit (individual/family) N/A N/A

PRESCRIPTION DRUG BENEFIT

Prescription drug deductible (individual/family) None Plan has integrated deductible

with medical (see above)**

Tier 1 – Generic drugs $10 copay $10 copay after deductible

Tier 2 – Preferred brand drugs $30 copay $30 copay after deductible

Tier 3 – Non-preferred brand drugs $50 copay $50 copay after deductible

Tier 4 – Specialty drugs 50% coinsurance$400 maximum per prescription

50% coinsurance$400 maximum per prescription

after deductible

*(A) means the plan has an “Aggregate” deductible. See page 6 for more information.**Integrated medical and prescription drug deductible.***Subject to limitations.

8 1-800-723-2986*(E) means the plan has an “Embedded” deductible. See page 6 for more information.**Integrated medical and prescription drug deductible.***Subject to limitations.

Choice EPO plansPlan name/Metal level

Contract-year Contract-year Contract-year Contract-year

Choice EPO Copay/Coins. $2000Ded CNT 06

Choice EPO Copay/Coins.$3000Ded CNT 06

Choice EPO 30/45$2500Ded 20% CNT 06

Choice EPO HSA Coins. $3000/$6000 CNT 06 (E)*


Deductible (individual/family) $2,000/$4,000 $3,000/$6,000 $2,500/$5,000 $3,000/$6,000**

Maximum out-of-pocket limit (individual/family) $4,000/$8,000 $6,000/$12,000 $5,000/$10,000 $6,000/$12,000


Preventive care/screenings/immunizations $0 $0 $0 $0

Primary care provider (PCP) services At a Sanitas Medical Center: $0


At a Sanitas Medical Center: $0 For all other primary care:

$30 copay (deductible waived)



At a Sanitas Medical Center: $0 after deductible

For all other primary care: 10% coinsurance after deductible

Specialist services 10% coinsurance after deductible $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance after deductible

Mental health and susbtance abuse office visits 10% coinsurance after deductible $30 copay (deductible waived) $30 copay (deductible waived) 10% coinsurance after deductible

Routine vision 10% coinsurance (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance (deductible waived)

Walk-in/urgent care center 10% coinsurance after deductible $75 copay (deductible waived) $75 copay (deductible waived) 10% coinsurance after deductible

Worldwide emergency coverage*** 10% coinsurance after deductible 20% coinsurance up to $300 per visit (deductible waived) $250 copay (deductible waived) 10% coinsurance after deductible

Hospital - inpatient treatment 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Hospital - outpatient treatment 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Outpatient surgery in freestanding locations 10% coinsurance after deductible $500 copay (deductible waived) 20% coinsurance after deductible 10% coinsurance after deductible

Lab services 10% coinsurance after deductible $10 copay (deductible waived) $10 copay (deductible waived) 10% coinsurance after deductible

X-rays 10% coinsurance after deductible $40 copay (deductible waived) $40 copay (deductible waived) 10% coinsurance after deductible

Advanced imaging (CT scans & MRI) 10% coinsurance after deductible

Freestanding facility: $75 copay up to $375 (deductible waived)

Hospital setting: 20% coinsurance after deductible


Hospital setting: $75 copay up to $375 after deductible

10% coinsurance after deductible


Deductible (individual/family) N/A N/A N/A N/A

Coinsurance N/A N/A N/A N/A

Maximum out-of-pocket limit (individual/family) N/A N/A N/A N/A


Prescription drug deductible (individual/family) None None None Plan has integrated deductible with medical (see above)**

Tier 1 – Generic drugs $10 copay $10 copay $10 copay $10 copay after deductible

Tier 2 – Preferred brand drugs $30 copay $30 copay $30 copay $30 copay after deductible

Tier 3 – Non-preferred brand drugs $50 copay $50 copay $50 copay $50 copay after deductible

Tier 4 – Specialty drugs 50% coinsurance $400 maximum per prescription

50% coinsurance $400 maximum per prescription



after deductible

391-800-723-2986*(E) means the plan has an “Embedded” deductible. See page 6 for more information.**Integrated medical and prescription drug deductible.***Subject to limitations.

Choice EPO plansPlan name/Metal level


Choice EPO Copay/Coins. $2000Ded CNT 06

Choice EPO Copay/Coins.$3000Ded CNT 06

Choice EPO 30/45$2500Ded 20% CNT 06

Choice EPO HSA Coins. $3000/$6000 CNT 06 (E)*


Deductible (individual/family) $2,000/$4,000 $3,000/$6,000 $2,500/$5,000 $3,000/$6,000**












Specialist services 10% coinsurance after deductible $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance after deductible

Mental health and susbtance abuse office visits 10% coinsurance after deductible $30 copay (deductible waived) $30 copay (deductible waived) 10% coinsurance after deductible

Routine vision 10% coinsurance (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance (deductible waived)

Walk-in/urgent care center 10% coinsurance after deductible $75 copay (deductible waived) $75 copay (deductible waived) 10% coinsurance after deductible

Worldwide emergency coverage*** 10% coinsurance after deductible 20% coinsurance up to $300 per visit (deductible waived) $250 copay (deductible waived) 10% coinsurance after deductible

Hospital - inpatient treatment 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Hospital - outpatient treatment 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Outpatient surgery in freestanding locations 10% coinsurance after deductible $500 copay (deductible waived) 20% coinsurance after deductible 10% coinsurance after deductible

Lab services 10% coinsurance after deductible $10 copay (deductible waived) $10 copay (deductible waived) 10% coinsurance after deductible

X-rays 10% coinsurance after deductible $40 copay (deductible waived) $40 copay (deductible waived) 10% coinsurance after deductible

Advanced imaging (CT scans & MRI) 10% coinsurance after deductible







Deductible (individual/family) N/A N/A N/A N/A

Coinsurance N/A N/A N/A N/A

Maximum out-of-pocket limit (individual/family) N/A N/A N/A N/A



Tier 1 – Generic drugs $10 copay $10 copay $10 copay $10 copay after deductible

Tier 2 – Preferred brand drugs $30 copay $30 copay $30 copay $30 copay after deductible

Tier 3 – Non-preferred brand drugs $50 copay $50 copay $50 copay $50 copay after deductible





after deductible

10 1-800-723-2986*(A) means the plan has an “Aggregate” deductible, and (E) means the plan has an “Embedded” deductible. See page 6 for more information.**Integrated medical and prescription drug deductible.***Subject to limitations.

Choice HMO plansPlan name/Metal level

Contract-year Contract-year Contract-year Contract-year Contract-year

Choice HMO 30/45

$1500Ded CNT 06

Choice HMO30/45

$3000Ded CNT 06

Choice HMO30/45

$5000Ded CNT 06

Choice HMO HSA$3000/$6000Ded

CNT 06 (A)*

Choice HMO HSA Copay $5000/$10000Ded

CNT 06 (E)*


Deductible (individual/family) $1,500/$3,000 $3,000/$6,000 $5,000/$10,000 $3,000/$6,000** $5,000/$10,000**

Maximum out-of-pocket limit (individual/family) $5,000/$10,000 $5,000/$10,000 $6,350/$12,700 $5,000/$10,000 $6,350/$12,700


Preventive care/screenings/immunizations $0 $0 $0 $0 $0






$30 copay (deductible waived)$0 after deductible


For all other primary care: $30 copay after deductible

Specialist services $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) $0 after deductible $45 copay after deductible

Mental health and substance abuse office visits $30 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived) $0 after deductible $30 copay after deductible

Routine vision $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) $0 (deductible waived) $45 copay (deductible waived)

Walk-in/urgent care center $75 copay (deductible waived) $75 copay (deductible waived) $75 copay (deductible waived) $0 after deductible $75 copay after deductible

Worldwide emergency coverage*** $250 copay (deductible waived) $250 copay (deductible waived) $250 copay (deductible waived) $0 after deductible $250 copay after deductible

Hospital - inpatient treatment $0 after deductible $0 after deductible $0 after deductible $0 after deductible$500 copay/day

$2,000 maximum per admission after deductible

Hospital - outpatient treatment $0 after deductible $0 after deductible $0 after deductible $0 after deductible $250 copay after deductible

Outpatient surgery in freestanding locations $0 after deductible $0 after deductible $0 after deductible $0 after deductible $125 copay after deductible

Lab services $0 (deductible waived) $0 (deductible waived) $0 (deductible waived) $0 after deductible $10 copay after deductible

X-rays $40 copay (deductible waived) $40 copay (deductible waived) $40 copay (deductible waived) $0 after deductible $40 copay after deductible

Advanced imaging (CT scans & MRI)







$0 after deductible $75 copay up to $375 after deductible


Deductible (individual/family) N/A N/A N/A N/A N/A

Coinsurance N/A N/A N/A N/A N/A

Maximum out-of-pocket limit (individual/family) N/A N/A N/A N/A N/A



Plan has integrated deductible with medical (see above)**

Tier 1 – Generic drugs $10 copay $10 copay $10 copay $10 copay after deductible $10 copay after deductible

Tier 2 – Preferred brand drugs $30 copay $30 copay $30 copay $30 copay after deductible $30 copay after deductible

Tier 3 – Non-preferred brand drugs $50 copay $50 copay $50 copay $50 copay after deductible $50 copay after deductible





after deductible


after deductible

3111-800-723-2986*(A) means the plan has an “Aggregate” deductible, and (E) means the plan has an “Embedded” deductible. See page 6 for more information.**Integrated medical and prescription drug deductible.***Subject to limitations.

Choice HMO plansPlan name/Metal level


Choice HMO 30/45

$1500Ded CNT 06

Choice HMO30/45

$3000Ded CNT 06

Choice HMO30/45

$5000Ded CNT 06

Choice HMO HSA$3000/$6000Ded

CNT 06 (A)*

Choice HMO HSA Copay $5000/$10000Ded

CNT 06 (E)*











$30 copay (deductible waived)$0 after deductible



Specialist services $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) $0 after deductible $45 copay after deductible

Mental health and substance abuse office visits $30 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived) $0 after deductible $30 copay after deductible

Routine vision $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) $0 (deductible waived) $45 copay (deductible waived)

Walk-in/urgent care center $75 copay (deductible waived) $75 copay (deductible waived) $75 copay (deductible waived) $0 after deductible $75 copay after deductible

Worldwide emergency coverage*** $250 copay (deductible waived) $250 copay (deductible waived) $250 copay (deductible waived) $0 after deductible $250 copay after deductible

Hospital - inpatient treatment $0 after deductible $0 after deductible $0 after deductible $0 after deductible$500 copay/day


Hospital - outpatient treatment $0 after deductible $0 after deductible $0 after deductible $0 after deductible $250 copay after deductible

Outpatient surgery in freestanding locations $0 after deductible $0 after deductible $0 after deductible $0 after deductible $125 copay after deductible

Lab services $0 (deductible waived) $0 (deductible waived) $0 (deductible waived) $0 after deductible $10 copay after deductible

X-rays $40 copay (deductible waived) $40 copay (deductible waived) $40 copay (deductible waived) $0 after deductible $40 copay after deductible








$0 after deductible $75 copay up to $375 after deductible


Deductible (individual/family) N/A N/A N/A N/A N/A

Coinsurance N/A N/A N/A N/A N/A

Maximum out-of-pocket limit (individual/family) N/A N/A N/A N/A N/A











after deductible


after deductible

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Choice POS plansPlan name/Metal level


Choice POSCopay/Coins.

$3000Ded CNT 06

Choice POS Copay/Coins.

$5000Ded CNT 06


$5000Ded 50% CNT 06

Choice POS HSA Coins.

$2500/$5000 CNT 06 (A)*


$4000/$8000 CNT 06 (E)*
















Specialist services $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Mental health and substance abuse office visits $30 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Routine vision $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance (deductible waived) 20% coinsurance (deductible waived)

Walk-in/urgent care center $75 copay (deductible waived) $75 copay (deductible waived) $75 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Worldwide emergency coverage*** 20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance up to $250 per visit (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Hospital - inpatient treatment 20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible 10% coinsurance after deductible 20% coinsurance after deductible

Hospital - outpatient treatment 20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible 10% coinsurance after deductible 20% coinsurance after deductible

Outpatient surgery in freestanding locations $500 copay (deductible waived) $500 copay (deductible waived) $500 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Lab services $10 copay (deductible waived) $10 copay (deductible waived) $10 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

X-rays $40 copay (deductible waived) $40 copay (deductible waived) $40 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Advanced imaging (CT scans & MRI) 20% coinsurance after deductible 20% coinsurance after deductible



10% coinsurance after deductible 20% coinsurance after deductible


Deductible (individual/family) $6,000/$12,000 $6,350/$12,700 $8,000/$16,000 $5,000/$10,000 $8,000/$16,000

Coinsurance 50% 50% 50% 50% 50%



Prescription drug deductible (individual/family) None None NonePlan has integrated

deductible with medical (see above)**

Plan has integrated deductible with medical

(see above)**








after deductible


after deductible

*(A) means the plan has an “Aggregate” deductible, and (E) means the plan has an “Embedded” deductible. See page 6 for more information.**Integrated medical and prescription drug deductible.***Subject to limitations.

3131-800-723-2986

Choice POS plansPlan name/Metal level


Choice POSCopay/Coins.

$3000Ded CNT 06


$5000Ded CNT 06


$5000Ded 50% CNT 06


$2500/$5000 CNT 06 (A)*


$4000/$8000 CNT 06 (E)*
















Specialist services $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Mental health and substance abuse office visits $30 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Routine vision $45 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) 10% coinsurance (deductible waived) 20% coinsurance (deductible waived)

Walk-in/urgent care center $75 copay (deductible waived) $75 copay (deductible waived) $75 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Worldwide emergency coverage*** 20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance up to $250 per visit (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible



Outpatient surgery in freestanding locations $500 copay (deductible waived) $500 copay (deductible waived) $500 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Lab services $10 copay (deductible waived) $10 copay (deductible waived) $10 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

X-rays $40 copay (deductible waived) $40 copay (deductible waived) $40 copay (deductible waived) 10% coinsurance after deductible 20% coinsurance after deductible

Advanced imaging (CT scans & MRI) 20% coinsurance after deductible 20% coinsurance after deductible






Coinsurance 50% 50% 50% 50% 50%



Prescription drug deductible (individual/family) None None NonePlan has integrated

deductible with medical (see above)**

Plan has integrated deductible with medical

(see above)**








after deductible


after deductible


14 1-800-723-2986

FlexPOS plansPlan name/Metal level


FlexPOS 30/50 Copay

CNT 06

FlexPOS 30/45

$1500Ded CNT 06

FlexPOS 40/50

$4000Ded CNT 06

FlexPOS Copay/Coins.

$1500Ded CNT 06


$2500Ded CNT 06


Deductible (individual/family) None $1,500/$3,000 $4,000/$8,000 $1,500/$3,000 $2,500/$5,000





For all other primary care: $30 copay









Specialist services $50 copay $45 copay (deductible waived) $50 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Mental health and susbtance abuse office visits $30 copay $30 copay (deductible waived) $40 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Routine vision $50 copay $45 copay (deductible waived) $50 copay (deductible waived) 25% coinsurance (deductible waived) 20% coinsurance (deductible waived)

Walk-in/urgent care center $75 copay $75 copay (deductible waived) $75 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Worldwide emergency coverage* $250 copay $250 copay (deductible waived) $250 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Hospital - inpatient treatment$500 copay/day

$2,000 maximum per admission

$0 after deductible $500 copay per admission after deductible 25% coinsurance after deductible 20% coinsurance after deductible

Hospital - outpatient treatment $500 copay $0 after deductible $500 copay after deductible 25% coinsurance after deductible 20% coinsurance after deductible

Outpatient surgery in freestanding locations $250 copay $0 after deductible $100 copay after deductible 25% coinsurance after deductible 20% coinsurance after deductible

Lab services $10 copay $10 copay (deductible waived) $10 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

X-rays $40 copay $40 copay (deductible waived) $40 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Advanced imaging (CT scans & MRI) $75 copay up to $375








Coinsurance 30% 30% 50% 50% 50%



Prescription drug deductible (individual/family) None None None None None

Tier 1 – Generic drugs $10 copay $10 copay $10 copay $10 copay $10 copay

Tier 2 – Preferred brand drugs $30 copay $30 copay $30 copay $30 copay $30 copay

Tier 3 – Non-preferred brand drugs $50 copay $50 copay $50 copay $50 copay $50 copay






*Subject to limitations.

3151-800-723-2986



FlexPOS 30/50 Copay

CNT 06

FlexPOS 30/45

$1500Ded CNT 06

FlexPOS 40/50

$4000Ded CNT 06


$1500Ded CNT 06


$2500Ded CNT 06


Deductible (individual/family) None $1,500/$3,000 $4,000/$8,000 $1,500/$3,000 $2,500/$5,000





For all other primary care: $30 copay









Specialist services $50 copay $45 copay (deductible waived) $50 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Mental health and susbtance abuse office visits $30 copay $30 copay (deductible waived) $40 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Routine vision $50 copay $45 copay (deductible waived) $50 copay (deductible waived) 25% coinsurance (deductible waived) 20% coinsurance (deductible waived)

Walk-in/urgent care center $75 copay $75 copay (deductible waived) $75 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Worldwide emergency coverage* $250 copay $250 copay (deductible waived) $250 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible


$2,000 maximum per admission

$0 after deductible $500 copay per admission after deductible 25% coinsurance after deductible 20% coinsurance after deductible

Hospital - outpatient treatment $500 copay $0 after deductible $500 copay after deductible 25% coinsurance after deductible 20% coinsurance after deductible

Outpatient surgery in freestanding locations $250 copay $0 after deductible $100 copay after deductible 25% coinsurance after deductible 20% coinsurance after deductible

Lab services $10 copay $10 copay (deductible waived) $10 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

X-rays $40 copay $40 copay (deductible waived) $40 copay (deductible waived) 25% coinsurance after deductible 20% coinsurance after deductible

Advanced imaging (CT scans & MRI) $75 copay up to $375








Coinsurance 30% 30% 50% 50% 50%












16 1-800-723-2986



FlexPOS Coins. 30/50

$3000Ded CNT 06


$5000Ded CNT 06


$2500Ded CNT 06


$3000Ded CNT 06


$5000Ded CNT 06








At a Sanitas Medical Center:$0 For all other primary care:








Specialist services $50 copay (deductible waived) $60 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) $50 copay (deductible waived)

Mental health and substance abuse office visits $30 copay (deductible waived) $60 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived)

Routine vision $50 copay (deductible waived) 30% coinsurance after deductible $45 copay (deductible waived) $45 copay (deductible waived) $50 copay (deductible waived)

Walk-in/urgent care center $75 copay (deductible waived) 30% coinsurance after deductible $75 copay (deductible waived) $75 copay (deductible waived) $75 copay (deductible waived)

Worldwide emergency coverage* $250 copay (deductible waived) 30% coinsurance after deductible $250 copay (deductible waived) $250 copay (deductible waived) $250 copay (deductible waived)



Outpatient surgery in freestanding locations 30% coinsurance after deductible 30% coinsurance after deductible 10% coinsurance after deductible 10% coinsurance after deductible 20% coinsurance after deductible

Lab services $10 copay (deductible waived) 30% coinsurance after deductible $10 copay (deductible waived) $10 copay (deductible waived) $10 copay (deductible waived)

X-rays $40 copay (deductible waived) 30% coinsurance after deductible $40 copay (deductible waived) $40 copay (deductible waived) $40 copay (deductible waived)


Freestanding facility: $75 copay up to $375 (deductible waived) Hospital setting:

$75 copay up to $375 after deductible










Coinsurance 50% 50% 50% 50% 50%













3171-800-723-2986




$3000Ded CNT 06


$5000Ded CNT 06


$2500Ded CNT 06


$3000Ded CNT 06


$5000Ded CNT 06
















Specialist services $50 copay (deductible waived) $60 copay (deductible waived) $45 copay (deductible waived) $45 copay (deductible waived) $50 copay (deductible waived)

Mental health and substance abuse office visits $30 copay (deductible waived) $60 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived)

Routine vision $50 copay (deductible waived) 30% coinsurance after deductible $45 copay (deductible waived) $45 copay (deductible waived) $50 copay (deductible waived)

Walk-in/urgent care center $75 copay (deductible waived) 30% coinsurance after deductible $75 copay (deductible waived) $75 copay (deductible waived) $75 copay (deductible waived)

Worldwide emergency coverage* $250 copay (deductible waived) 30% coinsurance after deductible $250 copay (deductible waived) $250 copay (deductible waived) $250 copay (deductible waived)



Outpatient surgery in freestanding locations 30% coinsurance after deductible 30% coinsurance after deductible 10% coinsurance after deductible 10% coinsurance after deductible 20% coinsurance after deductible

Lab services $10 copay (deductible waived) 30% coinsurance after deductible $10 copay (deductible waived) $10 copay (deductible waived) $10 copay (deductible waived)

X-rays $40 copay (deductible waived) 30% coinsurance after deductible $40 copay (deductible waived) $40 copay (deductible waived) $40 copay (deductible waived)













Coinsurance 50% 50% 50% 50% 50%













18 1-800-723-2986



FlexPOS HSA Copay $1500/$3000 CNT 06 (A)*

FlexPOS HSA Coins.$2000/$4000 CNT 06 (A)*

FlexPOS HSA Coins.$2800/$5600 CNT 06 (E)*

FlexPOS HSA Coins.$6000/$12000 10

CNT 06 (E)*


Deductible (individual/family) $1,500/$3,000** $2,000/$4,000** $2,800/$5,600** $6,000/$12,000**




Primary care provider (PCP) services








Specialist services $45 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Mental health and substance abuse office visits $30 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Routine vision $45 copay (deductible waived) 20% coinsurance (deductible waived) 20% coinsurance (deductible waived) 10% coinsurance (deductible waived)

Walk-in/urgent care center $75 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Worldwide emergency coverage*** $250 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible



20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Hospital - outpatient treatment $250 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Outpatient surgery in freestanding locations $125 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Lab services $10 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

X-rays $40 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Advanced imaging (CT scans & MRI) $75 copay up to $375 after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible


Deductible (individual/family) $3,000/$6,000 $5,000/$10,000 $5,000/$10,000 $10,000/$20,000

Coinsurance 30% 50% 50% 30%



Prescription drug deductible (individual/family) Plan has integrated deductible with medical (see above)**




Tier 1 – Generic drugs $10 copay after deductible $10 copay after deductible $10 copay after deductible $10 copay after deductible

Tier 2 – Preferred brand drugs $30 copay after deductible $30 copay after deductible $30 copay after deductible $30 copay after deductible

Tier 3 – Non-preferred brand drugs $50 copay after deductible $50 copay after deductible $50 copay after deductible $50 copay after deductible

Tier 4 – Specialty drugs50% coinsurance

$400 maximum per prescription after deductible


after deductible


after deductible


after deductible


3191-800-723-2986



FlexPOS HSA Copay $1500/$3000 CNT 06 (A)*

FlexPOS HSA Coins.$2000/$4000 CNT 06 (A)*

FlexPOS HSA Coins.$2800/$5600 CNT 06 (E)*

FlexPOS HSA Coins.$6000/$12000 10

CNT 06 (E)*














Specialist services $45 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Mental health and substance abuse office visits $30 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Routine vision $45 copay (deductible waived) 20% coinsurance (deductible waived) 20% coinsurance (deductible waived) 10% coinsurance (deductible waived)

Walk-in/urgent care center $75 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Worldwide emergency coverage*** $250 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible



20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Hospital - outpatient treatment $250 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Outpatient surgery in freestanding locations $125 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Lab services $10 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

X-rays $40 copay after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible

Advanced imaging (CT scans & MRI) $75 copay up to $375 after deductible 20% coinsurance after deductible 20% coinsurance after deductible 10% coinsurance after deductible
















after deductible


after deductible


after deductible


20 1-800-723-2986



FlexPOS HSA Copay$3500/$7000 CNT 06 (E)*

FlexPOS HSA $2500/$5000 CNT 06 (A)*

FlexPOS HSA$3000/$6000 CNT 06 (A)*

FlexPOS HSA $5000/$10000

CNT 06 (A)*









$0 after deductible $0 after deductible $0 after deductible

Specialist services $45 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Mental health and substance abuse office visits $30 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Routine vision $45 copay (deductible waived) $0 (deductible waived) $0 (deductible waived) $0 (deductible waived)

Walk-in/urgent care center $75 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Worldwide emergency coverage*** $250 copay after deductible $0 after deductible $0 after deductible $0 after deductible




Hospital - outpatient treatment $250 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Outpatient surgery in freestanding locations $125 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Lab services $10 copay after deductible $0 after deductible $0 after deductible $0 after deductible

X-rays $40 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Advanced imaging (CT scans & MRI) $75 copay up to $375 after deductible $0 after deductible $0 after deductible $0 after deductible
















after deductible


after deductible


after deductible


3211-800-723-2986



FlexPOS HSA Copay$3500/$7000 CNT 06 (E)*

FlexPOS HSA $2500/$5000 CNT 06 (A)*

FlexPOS HSA$3000/$6000 CNT 06 (A)*

FlexPOS HSA $5000/$10000

CNT 06 (A)*










Specialist services $45 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Mental health and substance abuse office visits $30 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Routine vision $45 copay (deductible waived) $0 (deductible waived) $0 (deductible waived) $0 (deductible waived)

Walk-in/urgent care center $75 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Worldwide emergency coverage*** $250 copay after deductible $0 after deductible $0 after deductible $0 after deductible




Hospital - outpatient treatment $250 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Outpatient surgery in freestanding locations $125 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Lab services $10 copay after deductible $0 after deductible $0 after deductible $0 after deductible

X-rays $40 copay after deductible $0 after deductible $0 after deductible $0 after deductible

Advanced imaging (CT scans & MRI) $75 copay up to $375 after deductible $0 after deductible $0 after deductible $0 after deductible
















after deductible


after deductible


after deductible


1 Subject to limitations.2 Deductible may apply. Check summary of benefits for plan details. Sanitas is an independent medical center. Other providers are available in the ConnectiCare networks.ConnectiCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-251-7722 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-251-7722 (TTY: 711). ©2019 ConnectiCare, Inc. & Affiliates.

PREFPORTBROCH 1019

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