Page 15 - 2021-2022 New Hire Benefits

Getting care outside of our network

Generally your plan does not cover services rendered outside of our network. Please refer to your member
documents for additional plan information.

To ensure that you use services within our network, please visit www.connecticare.com and use the "Find a
doctor" option to search for doctors and facilities.

Important information
• This is a brief summary of bene ts. Refer to your Membership Agreement for complete details on
bene ts, conditions, limitations and exclusions, or consult with your bene ts manager. All bene ts
described are per member per Contract year.
• Mammogram screenings, breast ultrasounds, and breast MRIs - Please refer to you Membership
Agreement for details.
• 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.
• If you are a Massachusetts resident, please refer to your amendatory rider for Massachusetts
manadated bene ts for additional details of your bene ts.
• If you are a Massachusetts resident, this plan along with pharmacy services meet Massachusetts
Minimum Creditable Coverage standards for 2021.

CCI/HMO/BS LG (01/2021) E ective Date: 7/2021
Choice_HMO-OA-129630
CT H00154139 / MA H01254140 -129630
Choice HMO-OA-CNT-30-45-300-500D-01
Bene t ID: Lk