Page 21 - 2021-2022 New Hire Benefits
P. 21

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
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