SOLO Member Guidebook

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Individual POS DEDUCTIBLE PLAN OPTIONS POS Deductible $5,000/$10,000 - F CALENDAR YEAR COST-SHARE In-Network Out-of-Network Individual / Family Plan Deductible $5,000 / $10,000 $5,000 / $10,000 Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription services) $6,600 / $13,200 $10,000 / $20,000 Member Coinsurance Not applicable 50% Lifetime Maximum Benefit Unlimited Unlimited COVERED HEALTH SERVICES In-Network Member Cost Out-of-Network Member Cost Routine Physical Exam No Member cost 50% after Plan Deductible Gynecological Preventive Exam Office Services No Member cost 50% after Plan Deductible Primary Care Providers Office Services $30 Copayment per visit 50% after Plan Deductible Specialist Office Services $50 Copayment per visit 50% after Plan Deductible Outpatient Laboratory Services $30 Copayment per visit 50% after Plan Deductible Non-Advanced Radiology Services $50 Copayment per visit 50% after Plan Deductible Advanced Radiology Services (includes MRI, PET and CAT Scan) $75 Copayment per visit after Plan Deductable up to 5 Copayments per year 50% after Plan Deductible Outpatient Rehabilitative Therapy (up to 40 visits) $30 Copayment per visit 50% after Plan Deductible Chiropractic Services (up to 20 visits) $50 Copayment per visit 50% after Plan Deductible Walk-In / Urgent Care Services $75 Copayment per visit Same as In-Network Emergency Room $200 Copayment per visit Same as In-Network Emergency Ambulance Services No Member cost Same as In-Network Outpatient Ambulatory Services No Member cost after Plan Deductible 50% after Plan Deductible Hospitalization for Illness or Injury No Member cost after Plan Deductible 50% after Plan Deductible Home Health Services (up to 100 visits) $30 Copayment per visit 25% (Plan Deductible Waived) Skilled Nursing and Rehabilitation Facilities (up to 90 days) No Member cost after Plan Deductible 50% after Plan Deductible Durable Medical Equipment & Disposable Medical Supplies 50% 50% after Plan Deductible POS DED PLANS – 1 OF 2 Rates displayed are quoted rates only. Final rates are subject to Department of Insurance approval. Rates and benefits are subject to change based on any state or federal mandate or other regulatory requirements. 16
PRESCRIPTION DRUG OPTION Tier 1 Tier 2 Tier 3 Tier 4 Option I – 30-Day supply through participating retail pharmacies $5 $50 ($200 Deductible) 50% ($200 Deductible) 50% ($200 Deductible) (Copay is 2X through mail-order) $150 Coins Max per Script $500 Coins Max per Script POS DED PLANS – 2 OF 2 17
Page 1 and 2: 2015 MEMBER GUIDEBOOK FOR CONNECTIC
Page 3 and 4: TABLE OF CONTENTS 1. Why ConnectiCa
Page 5 and 6: WHY CONNECTICARE? • Your health i
Page 7 and 8: HOW TO USE • An individual adequa
Page 9 and 10: RATING AREAS RATING AREA THREE RATI
Page 11 and 12: WHICH PLAN? 5. WHICH PLAN IS RIGHT
Page 13 and 14: WHICH PLAN? ConnectiCare SOLO High-
Page 15 and 16: PLAN COMPARISON CHARTS 13
Page 17: PRESCRIPTION DRUG OPTION Tier 1 Tie
Page 21 and 22: Individual POS Upfront Deductible P
Page 31 and 32: Individual HMO High-Deductible Heal
Page 33 and 34: Individual POS High Deductible Heal
Page 35 and 36: Individual POS High Deductible Heal
Page 37 and 38: Preventive Care and Wellness Servic
Page 39 and 40: WHICH PLAN? • Routine hearing scr
Page 41 and 42: HEALTH SAVINGS ACCOUNT UNDERSTANDIN
Page 43 and 44: 41
Page 45 and 46: HEALTH SAVINGS ACCOUNTS Example #2
Page 47 and 48: HOW TO APPLY • A dependent loses
Page 49 and 50: HOW TO APPLY Renewability of Covera
Page 51 and 52: VALUE-ADDED SERVICES 45 states that
Page 53: CONTACT US 9. HOW TO CONTACT US TEL
Page 56: 175 Scott Swamp Road, Farmington, C

SOLO Member Guidebook

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