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CICI/POS OA/IND/BS 01 (1/2008) Effective Date: 8/2008POS-OA-25-35-A102984POS-OA-25-35-AJLA-IND No Rx Line
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POS-OA-25-35-AJLA-IND POS Open Access Benefit SummaryThis is a brief summary of benefits. Refer to your ConnectiCare Insurance Company, Inc. Policy for more information. The Policy will prevail forall benefits, conditions, limitations and exclusions. It is important that you read your Policy. All benefits described below are per Member percalendar year. All benefit limits/maximums are listed in the Plan pays column of this summary. A Referral from your Primary Care Physician isnot required.
IN-NETWORK OUT-OF-NETWORK
Calendar Year Plan Deductible None $5,000 per Individual$10,000 per Family
Out-of-Pocket Maximum(includes Plan Deductible andCoinsurance)
None $10,000 per Individual$20,000 per Family
Out-of-Network Reimbursement None Plan will reimburse up to the MaximumAllowable Amount.
Lifetime Maximum Benefit Unlimited $1,000,000 per Member
PREVENTIVE SERVICES MEMBER PAYS PLAN PAYS MEMBER PAYS PLAN PAYS
Adult Annual Preventive CareServices(includes services provided in a PrimaryCare Physician’s office)
$25 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Infant / Pediatric Preventive CareServices(includes services provided in a PrimaryCare Physician’s office)
$25 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Gynecological Annual PreventiveExam Office Services
$35 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Annual Routine Mammography(over age 40)
No Member cost 100% 30% after PlanDeductible
70% after PlanDeductible
Annual Routine Vision Exam $35 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
CICI/POS OA/IND/BS 01 (1/2008) Effective Date: 8/2008POS-OA-25-35-A102984POS-OA-25-35-AJLA-IND No Rx Line
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OUTPATIENT SERVICES
Primary Care Physician OfficeServices(includes services for illness, injury,sickness, follow-up care andconsultations)
$25 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Specialist Office Services(includes services for illness, injury,sickness, follow-up care andconsultations)
$35 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Maternity Care Office Services Not a covered benefit Not a covered benefit Not a covered benefit Not a covered benefit
Allergy Testing Applicable officevisit Copayment upto the benefitmaximum; then nocoverage
100% afterCopayment up to$315 every two years
30% after PlanDeductible up to thebenefit maximum;then no coverage
70% after PlanDeductible up to$315 every two years
Laboratory Services(includes services performed in a Hospitalor laboratory facility)
No Member cost 100% 30% after PlanDeductible
70% after PlanDeductible
Non-Advanced Radiology(includes x-rays performed in a Hospitalor radiology facility)
$10 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Advanced Radiology(includes services for MRI, PET and CATscan and nuclear cardiology performed ina Hospital or radiology facility)
$75 Copayment pervisit up to fiveCopayments per year
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Outpatient Rehabilitative Therapy(includes services combined for physical,speech, and occupational therapy)
$35 Copayment pervisit up to the visitmaximum; then nocoverage
100% afterCopayment up to 20visits per year
30% after PlanDeductible up to thevisit maximum; thenno coverage
70% after PlanDeductible up to 20visits per year
Chiropractic Services $35 Copayment pervisit up to the visitmaximum; then nocoverage
100% afterCopayment up to 10visits per year
30% after PlanDeductible up to thevisit maximum; thenno coverage
70% after PlanDeductible up to 10visits per year
EMERGENCY / URGENT CARE
Walk-In/Urgent Care Centers $50 Copayment pervisit
100% afterCopayment
$50 Copayment pervisit
100% afterCopayment
Emergency Room(Copayments waived if admitted)
$150 Copayment pervisit
100% afterCopayment
$150 Copayment pervisit
100% afterCopayment
Ambulance Services No Member cost 100% No member costafter Plan Deductible
100% after PlanDeductible
CICI/POS OA/IND/BS 01 (1/2008) Effective Date: 8/2008POS-OA-25-35-A102984POS-OA-25-35-AJLA-IND No Rx Line
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HOSPITAL SERVICES
Semi Private Room & Board(excludes all maternity related services)
$500 Copayment perday up to $2,000 peryear
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Ambulatory Services (Outpatient)(includes services performed in a Hospitalor ambulatory facility)
$500 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Skilled Nursing and RehabilitationFacilities
No Member cost upto the visitmaximum; then nocoverage
100% up to 90 days 30% after PlanDeductible up to thevisit maximum; thenno coverage
70% after PlanDeductible up to 90days
MENTAL HEALTH SERVICES
Inpatient Mental Health Services $500 Copayment perday up to $2,000 peryear
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Inpatient Alcohol and SubstanceAbuse Treatment
$500 Copayment perday up to $2,000 peryear
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
Outpatient Mental Health, Alcoholand Substance Abuse Treatment
$35 Copayment pervisit
100% afterCopayment
30% after PlanDeductible
70% after PlanDeductible
OTHER SERVICES
(All maximums are combined for in- and out-of-network and are per Member per calendar year)
Disposable Medical Supplies 20% up to the benefitmaximum; then nocoverage
80% up to $300 peryear
30% after PlanDeductible up to thebenefit maximum;then no coverage
70% after PlanDeductible up to$300 per year
Durable Medical EquipmentIncluding Prosthetics
20% up to the benefitmaximum; then nocoverage
80% up to $1,500 peryear
30% after PlanDeductible up to thebenefit maximum;then no coverage
70% after PlanDeductible up to$1,500 per year
Ostomy Supplies and Equipment 20% up to the benefitmaximum; then nocoverage
80% up to $1,000 peryear
30% after PlanDeductible up to thebenefit maximum;then no coverage
70% after PlanDeductible up to$1,000 per year
Home Health Services No Member cost upto the visitmaximum; then nocoverage
100% up to 100 visitsper year
25% up to the benefitmaximum; then nocoverage
75% up to 100 visitsper year
CICI/POS OA/IND/BS 01 (1/2008) Effective Date: 8/2008POS-OA-25-35-A102984POS-OA-25-35-AJLA-IND No Rx Line
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Important Information
• 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.• Many services require that you obtain our Pre-Certification or Pre-Authorization prior to obtaining care prescribed or rendered by Non-
Participating providers or a Benefit Reduction will apply. For mental health, alcohol, and substance abuse services call 1-888-946-4658 toobtain Pre-Authorization.
• We track benefits internally and do not provide Members with a regular update of benefits that have been used. Members should keep a recordof benefits they use to determine when they reached their benefit limit. Members will be responsible for paying in full any services renderedafter the limit is reached.
• Out-of-Network reimbursement is based on the Maximum Allowable Amount. Members are responsible to pay any charges in excess of thisamount. Please refer to your ConnectiCare Inc. Policy for more information.
• This plan is insured by ConnectiCare Insurance Company, Inc.
