2024 Preferred (HMO) Plan
The CareAdvantage Preferred (HMO) Plan is our $0 premium plan, designed for those who want a low cost Medicare option without compromising on coverage. Plan highlights:
- $0 monthly premium and $0 medical deductible
- $3,000 of dental coverage—one of the state's leading dental benefits
- $0 tier 6 vaccines, Rx deductible and select generic drugs
- $175 CarePerks Wellness Allowance
- $150 CarePerks Weight Management Program Allowance
- No in-network referrals required
Drugs and Drug Deductibles
Drug costs shown for Tier 1 and Tier 2 are reflective of Preferred Pharmacy pricing. Tier 1 and Tier 2 drugs include enhanced coverage of certain drugs such as select erectile dysfunction (ED) drugs, vitamins and minerals, and cough/cold products. Please use our Preferred Pharmacy Directory at carepartnersct.com/pharmacy to find a location near you.
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Drug Deductible
$0
Gap Coverage: Once you and your plan have spent $5,030 on covered drugs combined, you're in the Coverage Gap Stage where the 30-day supply costs are: $0 for Tier 6 vaccine drugs, $35 for covered insulin drugs, and 25% of the cost for Part D generic and brand name drugs, plus a portion of the dispensing fee for Tiers 1-5.
Catastrophic Coverage: Once you've spent $8,000 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage. If you reach the Catastrophic Coverage Stage, you pay nothing for covered Part D drugs and for excluded drugs that are covered under our enhanced benefit
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Tier 1 - Preferred Generic Drugs
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Initial Coverage Stage
$0 for 30-day retail supply; $0 for 90-day mail order supply
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Tier 2 - Non-Preferred Generic Drugs
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Initial Coverage Stage
$0 for 30 day retail supply; $0 for 90 day mail order supply
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Tier 3 - Preferred Brand Name Drugs
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Initial Coverage Stage
$47 ($35 for insulin) for 30 day retail supply; $94 ($70 for insulin) for 90 day mail order supply
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Tier 4 - Non-Preferred Drugs (includes Brand Name and Generic)
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Initial Coverage Stage
$100 ($35 for insulin) for 30-day retail supply; $200 ($70 for insulin) for 90-day mail order supply
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Tier 5 - Specialty Drugs
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Initial Coverage Stage
33% of cost for 30-day retail supply
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Tier 6 - Vaccines
$0
Plan Essentials
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Deductible
$0
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Maximum Out of Pocket
$4,900
Routine Doctor Visits and Checkups
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Primary Care Provider (PCP)
$0 per visit
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Telehealth
$0 copay for e-visits, virtual check-ins, and remote patient monitoring with your PCP or Specialist.
For all other telehealth visits, copay is the same as corresponding in-person visit copay-
Laboratory Services
$0 per day for Lab Services. Prior Authorization may be required.
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Routine Vision Exam
$15 per annual visit
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Routine Hearing Exam
$0 per annual visit
Specialty Visits, Surgery, and Exams
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Specialist Copay
$45 per visit
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X-Rays
$30 per day. Prior Authorization may be required.
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Diagnostic Procedures
$30 per day. Prior Authorization may be required.
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Diagnostic Radiology Services
Ultrasound: $60 per day; Others: $250 per day. Prior Authorization may be required.
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Outpatient Surgery
Colonoscopies: $0; Other outpatient surgeries (Ambulatory Surgical Center, ASC): $270 per day; Other outpatient surgeries (Non-ASC): $370 per day. Prior Authorization may be required.
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Physical, Occupational, and Speech Therapy
$30 per visit
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Cardiovascular Screening
$0 per annual visit
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Cancer Screening (Colorectal, Prostate, Breast)
$0 per annual visit
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Colonoscopy
$0
Unforeseen Care, Emergency Services, and Hospital Stays
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Urgent Care
$45 per visit
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but, given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers.
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Emergency Room Visits
$90 per visit. There is no limit to the number of visits in a plan year
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Inpatient Hospital Coverage
$395 per day for days 1-5. After day 5 you will pay $0 per day. Prior Authorization may be required.
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Ambulance Rides and Services
$300 per one-way trip for medically necessary Ambulance Services. Prior authorization may be required for non-emergency transportation. Includes worldwide emergency transportation coverage.
Embedded Dental Benefits
Access to thousands of dentists across the region. No waiting period. What you pay for covered services may vary depending on whether your provider is in-network or out-of-network. Additional restorative services covered at 20% of total cost; and comprehensive services covered at 50% of total cost, including surgical implant placements. For more detailed plan coverage information see your Evidence of Coverage (EOC).
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Individual Annual Deductible
$0
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Calendar Year Maximum
The plan pays up to the calendar year maximum of $3,000.
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Periodic Oral Evaluation
$0 copay; Two per year.
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Comprehensive Oral Exam
$0 copay; Once every 36 months (includes the initial dental history and charting of teeth).
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Intra Oral Bitewing X-ray (X-rays of Crowns of Teeth)
$0 copay; Two per year (when oral conditions indicate need).
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Intra Oral X-ray - Entire Mouth (Panoramic & Full Mouth)
20% coinsurance; Once every 60 months.
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Single Tooth X-ray Images
20% coinsurance; As needed.
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Fluoride Treatment
$0 copay; Two per year
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Periodontal Cleaning
50% coinsurance; Once every 6 months following active periodontal therapy, not to be combined with regular cleanings
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Simple Extractions
50% coinsurance; Once per tooth.
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Surgical Extractions
50% coinsurance; Once per tooth.
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Bridge or Denture Repair
50% coinsurance; Once every 24 months per bridge or denture.
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Dentures (Complete or Partial)
50% coinsurance; Once per arch within 84 months.
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Crowns and Onlays (Initial Placement)
50% coinsurance; Once within 84 months per tooth (when teeth cannot be restored with regular filings due to fracture or decay).
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Surgical Implant Placement Implants
50% coinsurance; Implants are limited to 1 per tooth per 5 years. Implant coverage is limited to the surgical placement of an endosteal implant (in lieu of a 3-unit bridge), abutment supported porcelain and cast metal crowns, and implant supported crowns.
Exclusions: the following implant related procedures are excluded: implant maintenance, repairs, re-cement/re-bond, removal of implants, implant and abutment supported fixed partial denture retainers, and implant/abutment supported removable dentures.
Benefits
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CarePerks Wellness Allowance
$175 per calendar year. Reimbursement of fees to qualified health clubs, participation in instructional fitness classes, nutritional counseling, memory fitness activities, wellness programs, activity tracker (every 3 years), additional acupuncture services beyond Medicare coverage, and more.
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CarePerks Weight Management Programs
$150 per calendar year. Reimbursement for program fees for weight loss programs such as Weight Watchers or hospital-based weight loss programs. Does not include meals or other program items, such as scales.
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SilverSneakers Membership
You receive a SilverSneakers fitness membership at no additional cost giving you access to 16,000+ gyms nationwide, trained instructors, classes and health and nutrition tips with exercise videos.
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Over-The-Counter (OTC) Bonus
$67 every calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes. Members receive an OTC card loaded quarterly with credit to use towards covered OTC items at participating retailers and plan approved online stores. No rollover of unused quarterly balances. See Evidence of Coverage (EOC) for more information.
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Acupuncture
$20 per visit. Covers up to 12 visits in 90 days for members with chronic lower back pain. 8 additional visits covered for those demonstrating an improvement. No more than 20 visits administered annually. Additional acupuncture services are eligible for reimbursement under your Wellness Allowance.
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Hearing Aid Benefit
You are eligible for up to 2 covered hearing aids per year, 1 aid per ear. . To be covered, the hearing aids must be on the Hearing Care Solutions formulary and must be purchased through Hearing Care Solutions. Different copays apply.
$250 Standard Level
$475 Superior Level
$650 Advanced Level
$850 Advanced Plus Level
$1,150 Premier Level
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Eyewear Benefit
$150 annual allowance through EyeMed; $90 per calendar year for non-Eyemed provider. Use for standard eyeglasses (prescription lenses, frames, or a combination of lenses and frames) and/or contact lenses.