Page 18 - 2021-2022 New Hire Benefits

FlexPOS-CNT-30-45-300-500D-01 Open Access Contract Year
Bene t Summary

Your ConnectiCare health plan helps you get the care you need. Here are the most frequently used services.
Refer to your certi cate of coverage on connecticare.com for a complete list of bene ts.

Personalized for: CISHP

In-Network Preventive Services
These services are no cost to you when you use an in-network doctor or facility. Frequency is based on age
and gender. For a complete list of preventive services and to nd a doctor, refer to connecticare.com.
Getting care within ConnectiCare’s network typically costs you less. You may also get care outside of our
network; however, your share of the costs will be higher. Out-of-network doctors and facilities do not appear
in the “Find a doctor” directory on connecticare.com.

• Physical • Flu shot
• Well woman visit and pap test • Vaccinations
• More than 25 screenings, including • Certain birth control and other prevention
mammograms and colonoscopies medications

In-network member pays Out-of-network member pays
$0 Individual $500 Individual
Your deductible
$0 Family $1,000 Family
Your out-of-pocket maximum
Includes a combination of $4,000 Individual $4,000 Individual
deductible, copayments and $8,000 Family $8,000 Family
coinsurance for medical and
pharmacy services
Plan will reimburse the
Out-of-network reimbursement Not applicable coinsurance percentage of the
maximum allowable amount

After you have spent the out-of-pocket maximum amount, ConnectiCare will pay 100% of your covered
health care expenses for the remainder of the year.

Screenings In-network member pays Out-of-network member pays
Baseline routine 20% coinsurance
mammography No charge after plan deductible
(ages 35-39)
Annual routine mammography No charge 20% coinsurance
(age 40 or older) after plan deductible
20% coinsurance
Annual routine vision exam $45 copayment/visit
after plan deductible

CICI FlexPOS and Combined/BS LG (01/2021) E ective Date: 7/2021
FlexPOS-CNT-30129705
CT P01656449 / MA P01756450 -129705
FlexPOS-CNT-30-45-300-500D-01
Bene t ID: Lo