Page 21 - 2021-2022 New Hire Benefits

Supplies In-network member pays Out-of-network member pays

Arti cial Limbs
includes associated supplies and 20% coinsurance 50% coinsurance
after plan deductible
equipment
Diabetic equipment and 20% coinsurance 20% coinsurance
supplies after plan deductible
Modi ed food products and 50% coinsurance
specialized formula pharmacy 50% coinsurance after plan deductible
tier

Important information
• This is a brief summary of bene ts. Refer to your ConnectiCare Insurance Company, Inc. Certi cate of
Coverage 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 the Certi cate of
Coverage 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.
• Out-of-Network reimbursement is based on the maximum allowable amount. Members are responsible
to pay any charges in excess of this amount. Please refer to your ConnectiCare Insurance Company,
Inc. Certi cate of Coverage for more information.
• If you are a Massachusetts resident, please refer to your amendatory rider for Massachusetts
mandated bene ts for additional details of your bene ts.
• If you are a Massachusetts resident, this plan along with pharmacy services meets Massachusetts
Minimum Creditable Coverage standards for 2021.

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