Page 36 - 2021-2022 New Hire Benefits
P. 36

Choice HMO-OA-CNT-HSA-3000I/6000F-30-45-05 Contract Year
       Bene t Summary (E)


       The individual deductible and out-of-pocket maximum applies if you have coverage only for yourself. The
       family deductible and out-of-pocket maximum applies if you have coverage for yourself and one or more
       eligible dependents. Each individual on the family plan will only need to satisfy the individual deductible and
       out-of-pocket maximum, not the full family amount. Each individual's charges will accrue towards the family
       amounts.

       Your ConnectiCare health plan helps you get the care you need. Here are the most frequently used services.
       Refer to your membership agreement 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.



            •  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
        Your deductible
        Deductible is combined for            $3,000 Individual
        medical services and prescription     $6,000 Family
        drugs

        Your out-of-pocket maximum
        Includes a combination of             $4,500 Individual
        deductible, copayments and            $9,000 Family
        coinsurance for medical and
        pharmacy services
        After you have spent the in-network 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
        Baseline routine                      0% coinsurance
        mammography
        (ages 35-39)                          after plan deductible

        Annual routine mammography
        (age 40 or older)                     No charge

                                              $45 copayment/visit;
        Annual routine vision exam
                                              deductible does not apply




       CCI/HMO OA HDHP/BS LG (01/2021) E ective Date: 7/2021
       Choice_HMO-OA-129628
       CT H00155571 / MA H01255572 -129628
       Choice HMO-OA-CNT-HSA-3000I/6000F-30-45-05
       Bene t ID: bI
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