Page 27 - 2021-2022 New Hire Benefits

Supplies In-network member pays

Durable medical equipment 0% coinsurance
including prosthetics and after plan deductible
disposable medical supplies
Arti cial Limbs 0% coinsurance
includes associated supplies and
equipment after plan deductible

Diabetic equipment and 0% coinsurance
supplies after plan deductible
Modi ed food products and 0% coinsurance
specialized formula pharmacy after plan deductible
tier

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 OA HDHP/BS LG (01/2021) E ective Date: 7/2021
Choice_HMO-OA-129629
CT H00153596/H00153595 / MA H01253593/H01253594 -129629
Choice HMO-OA-CNT-HSA-2000I/4000F-30-45-04
Bene t ID: lp/LR