Page 33 - 2021-2022 New Hire Benefits

Mental Health and Substance In-network member pays Out-of-network member pays
Abuse
Outpatient mental health,
alcohol and substance abuse
treatment 0% coinsurance 30% coinsurance
after plan deductible
after plan deductible
intensive outpatient treatment and
partial hospitalization
Supplies In-network member pays Out-of-network member pays

Durable medical equipment 0% coinsurance 30% coinsurance
including prosthetics and after plan deductible after plan deductible
disposable medical supplies
Arti cial Limbs
includes associated supplies and 0% coinsurance 30% coinsurance
after plan deductible
after plan deductible
equipment
Diabetic equipment and 0% coinsurance 30% coinsurance
supplies after plan deductible after plan deductible

Modi ed food products and 0% coinsurance 30% coinsurance
specialized formula pharmacy
tier after plan deductible after plan deductible

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 Flex and Combined/BS LG (01/2021) E ective Date: 7/2021
FlexPOS-CNT-HS129631
CT P01654141/P01654142 / MA P01754144/P01754143 -129631
FlexPOS-CNT-HSA-2000I/4000F-30-45-08
Bene t ID: LS/LT