SOLO Product Options

2017 ConnectiCare® SOLOIndividual plans

11-800-723-2986

Welcome to ConnectiCare

This guide includes information about ConnectiCare’s 2017 SOLO plans. We’re pleased to offer you a range of plan options, giving you the benefits you need to stay healthy. No matter which plan you choose, you can count on ConnectiCare to provide you with personalized service and easy access to care that have helped make us the top choice in Connecticut for individual health plans.1

This year, ConnectiCare celebrates 35 years of helping make Connecticut a healthier place to live and work. Being a local company, our employees live and work in the same communities as our members, so we’re able to do more for them, whether it’s helping find a doctor or providing new, easier ways to get care and service, including:

• New way to get care at CliniSanitas Medical Centers, only for ConnectiCare members

• New ConnectiCare center in Manchester

Take a look at all we have to offer in this guide. When you’re ready, you can enroll directly with us by calling 1-800-723-2986. Or, call your broker.

Thank you again for considering ConnectiCare.

Sincerely,

Terri GuidoneVice President, Sales & Account Management ConnectiCare, Inc. & Affiliates

31-800-723-29862 chooseconnecticare.com

Benefits you needIn this guide, you’ll see a wide range of plan options. No matter which plan you choose, you’ll get:

Free preventive care2 for covered services like your annual checkup, screenings and more

Telemedicine through MDLIVE®3 – virtual doctor visits from home, office or on the go

Emergency and urgent care anywhere in the world

Prescription drug benefits

Vision benefits

Pediatric dental benefits

Access to our broad network including EVERY hospital in CT

Extras that don’t cost extraAs a ConnectiCare member, you’ll get more than just health insurance. You’ll have access to discounts and savings that can make a big difference!

Vision Discount Program If you wear glasses or contacts, you can save hundreds of dollars each year with discounts of up to 30% when you purchase frames, lenses and prescription contacts from a participating optician.

Healthy Alternatives ProgramYou can get discounts up to 30% off select health and wellness products and services from acupuncture to exercise classes and more!

College Tuition Rewards®4

You can save thousands on college tuition just for being a member. With this program, you can earn up to one full year’s tuition at more than 340 private colleges and universities. Find out more at tuitionrewards.com/cci.

RX

ConnectiCare center in Manchester

Opening in the fall of 2016, our new center is a place where members can enjoy educational and community events, pay their bill, or simply get answers to questions. And, starting in 2017, members can also get preventive care like flu shots and health assessments. Stop by and check it out: 1487 Pleasant Valley Road, Manchester, CT 06042.

New, easier ways to get care and serviceCliniSanitas Medical Centers, only for ConnectiCare membersThese medical centers offer ConnectiCare members one convenient place to get primary care, see specialists, get lab work, urgent care, and customer service for their ConnectiCare plan. With Spanish and English speaking staff, easy-to-schedule appointments and convenient hours, CliniSanitas really makes it easier to get care. Three centers will open in the fall of 2016 in Newington, Orange and Bridgeport.

Primary care: family medicine, internal medicine, pediatrics and gynecology

Urgent care walk-in including observation units

Specialists: cardiology, dermatology, orthopedics and more

Onsite laboratory and diagnostics

Care programs: diabetes, COPD, asthma, weight management and more


ConnectiCare® SOLO Choice plansWith ConnectiCare SOLO, you have a range of plans to choose from.

These plans let you manage your care, your way, giving you the freedom to see a specialist without a referral.

Choice HMO plans cover in-network services only, except for emergency and urgent care, which are covered worldwide.

Choice POS plans give you coverage with lower copays and coinsurance for in-network medical services, plus coverage for out-of-network medical services.

There are also Choice plans available with Health Savings Accounts (HSAs). An HSA is a savings account that you can fund with pre-tax dollars and use to pay for qualified health care expenses, including prescriptions.

Metal levelsSOLO plans are grouped by “metal” level to help you better understand how much of your medical expenses they will cover. Listed below are descriptions for premium ranges and out-of-pocket costs for each metal level.

Metal Level Premiums Your Out-of-Pocket Costs Plan Pays*

Bronze plans Lowest Highest 60%

Silver plans Moderate Moderate 70%

Gold plans Higher Lower 80%

*Average amount plan pays for covered services

ConnectiCare’s networks include thousands of doctors, pharmacies and EVERY hospital in Connecticut.

Prescription drug benefitsAll ConnectiCare SOLO plans include prescription drug benefits. To see if your drugs are covered, look at the ConnectiCare Freedom Formulary at chooseconnecticare.com for the most up-to-date list of covered drugs.

Covered prescription drugs are grouped into sections or tiers. A drug “tier” is a group of medicines within a similar price range. With the six-tier drug list, the categories of generic, brand-name and specialty drugs are each divided into tiers labeled “preferred” and “non-preferred.” Preferred drugs are clinically-proven medicines that will generally cost you less than non-preferred medicines. How much you pay for drugs in each tier can be found on pages 6-9.

Drug Tier Drug Class

Tier 1 Preferred Generic Drugs

Tier 2 Non-Preferred Generic Drugs

Tier 3 Preferred Brand Drugs

Tier 4 Non-Preferred Brand Drugs

Tier 5 Preferred Specialty Drugs

Tier 6 Non-Preferred Specialty Drugs

Review our plans and let us know if you have any questions.

By phone: 1-800-723-2986 Monday - Friday, 8 a.m. to 5 p.m.,

or call your broker

In person: At a ConnectiCare center Online: chooseconnecticare.com

71-800-723-29866 chooseconnecticare.com*Integrated medical and prescription drug deductible.

Choice SOLO plansPlan Name/Metal Level

Choice SOLO POS HSA $6,000/$12,000 ded.

Bronze

Choice SOLO HMO HSA $5,850/$11,700 ded.

Bronze

Choice SOLO POS Copay/Coins.

$5,000/$10,000 ded. Silver

Choice SOLO POS Coins.

$2,500/$5,000 upfront ded. Silver

PLAN/MEDICAL DEDUCTIBLE

Deductible (Individual/Family) $6,000/$12,000* $5,850/$11,700* $5,000/$10,000* $2,500/$5,000*

Maximum Out-of-Pocket Limit (Individual/Family) $6,550/$13,100 $6,550/$13,100 $7,150/$14,300 $6,500/$13,000

IN-NETWORK MEDICAL BENEFITS

Preventive Care/Screenings/Immunizations $0 $0 $0 $0

Primary Care Physician (PCP) Office Visits & Telemedicine $0 after deductible $0 after deductible $30 copay

(deductible waived)$30 copay

(deductible waived)

Specialist Office Visits $0 after deductible $0 after deductible $50 copay (deductible waived)

50% coinsuranceafter deductible

Vision $0(deductible waived)

$0(deductible waived)

$50 copay (deductible waived)


Walk-In/Urgent Care Center $0 after deductible $0 after deductible $75 copay (deductible waived)


Worldwide Emergency Coverage $0 after deductible $0 after deductible 20% coinsuranceafter deductible


Inpatient Hospital Coverage $0 after deductible $0 after deductible 20% coinsuranceafter deductible


Hospital Outpatient Facilities $0 after deductible $0 after deductible 20% coinsuranceafter deductible


Outpatient Surgery Free Standing Locations $0 after deductible $0 after deductible 20% coinsuranceafter deductible


Lab Services $0 after deductible $0 after deductible $10 copay (deductible waived)


X-Rays $0 after deductible $0 after deductible $40 copay (deductible waived)


Advanced Imaging (CT Scans & MRI) $0 after deductible $0 after deductible 20% coinsuranceafter deductible

50% coinsurance after deductible

OUT-OF-NETWORK MEDICAL BENEFITS

Deductible (Individual/Family) $10,000/$20,000 N/A $10,000/$20,000 $5,000/$10,000

Coinsurance 50% N/A 50% 50%

Maximum Out-of-Pocket Limit (Individual/Family) $20,000/$40,000 N/A $20,000/$40,000 $15,000/$30,000

PRESCRIPTION DRUG BENEFIT

Prescription Drug Deductible (Individual/Family)Plan has integrated

deductible with medical (see above)*

Plan has integrated deductible with medical

(see above)*


(see above)*


(see above)*

Tier 1 – Preferred Generic Drugs $5 copay after deductible $5 copay after deductible $5 copay (deductible waived)


Tier 2 – Non-Preferred Generic Drugs50% coinsurance

$200 maximum per prescription after deductible

50% coinsurance $200 maximum per prescription

after deductible

50% coinsurance$200 maximum per prescription

after deductible


after deductible

Tier 3 – Preferred Brand Drugs $60 copay after deductible $60 copay after deductible $60 copay (deductible waived)


Tier 4 – Non-Preferred Brand Drugs50% coinsurance



after deductible


after deductible


after deductible

Tier 5 – Preferred Specialty Drugs50% coinsurance



after deductible


after deductible


after deductible

Tier 6 – Non-Preferred Specialty Drugs50% coinsurance



after deductible


after deductible


after deductible

91-800-723-29868 chooseconnecticare.com*Integrated medical and prescription drug deductible.

Choice SOLO plansPlan Name/Metal Level


$4,500/$9,000 ded. Silver

Choice SOLO POS HSA Coins.

$3,000/$6,000 ded. Silver


$1,000/$2,000 ded. Gold

PLAN/MEDICAL DEDUCTIBLE

Deductible (Individual/Family) $4,500/$9,000* $3,000/$6,000* $1,000/$2,000*

Maximum Out-of-Pocket Limit (Individual/Family) $7,150/$14,300 $5,000/$10,000 $5,000/$10,000

IN-NETWORK MEDICAL BENEFITS

Preventive Care/Screenings/Immunizations $0 $0 $0

Primary Care Physician (PCP) Office Visits & Telemedicine

$30 copay(deductible waived) 20% coinsurance after deductible $30 copay

(deductible waived)

Specialist Office Visits $45 copay (deductible waived) 20% coinsurance after deductible $45 copay

(deductible waived)

Vision $45 copay (deductible waived)

20% coinsurance(deductible waived)

$45 copay(deductible waived)

Walk-In/Urgent Care Center 20% coinsuranceafter deductible 20% coinsurance after deductible $75 copay

after deductible

Worldwide Emergency Coverage 20% coinsuranceafter deductible 20% coinsurance after deductible $200 copay

after deductible

Inpatient Hospital Coverage 20% coinsuranceafter deductible 20% coinsurance after deductible 20% coinsurance

after deductible

Hospital Outpatient Facilities 20% coinsuranceafter deductible 20% coinsurance after deductible 20% coinsurance

after deductible

Outpatient Surgery Free Standing Locations 20% coinsuranceafter deductible 20% coinsurance after deductible $500 copay

after deductible

Lab Services 20% coinsuranceafter deductible 20% coinsurance after deductible 20% coinsurance

after deductible

X-Rays 20% coinsuranceafter deductible 20% coinsurance after deductible 20% coinsurance

after deductible

Advanced Imaging (CT Scans & MRI)20% coinsuranceafter deductible 20% coinsurance after deductible 20% coinsurance

after deductible

OUT-OF-NETWORK MEDICAL BENEFITS

Deductible (Individual/Family) $10,000/$20,000 $7,000/$14,000 $5,000/$10,000

Coinsurance 50% 50% 50%

Maximum Out-of-Pocket Limit (Individual/Family) $12,500/$25,000 $15,000/$30,000 $10,000/$20,000

PRESCRIPTION DRUG BENEFIT

Prescription Drug Deductible (Individual/Family)Plan has integrated

deductible with medical (see above)*


(see above)*


(see above)*

Tier 1 – Preferred Generic Drugs $5 copay (deductible waived) $5 copay after deductible $5 copay

(deductible waived)

Tier 2 – Non-Preferred Generic Drugs50% coinsurance

$200 maximum per prescriptionafter deductible


after deductible


after deductible

Tier 3 – Preferred Brand Drugs $60 copay (deductible waived) $60 copay after deductible $50 copay

(deductible waived)

Tier 4 – Non-Preferred Brand Drugs50% coinsurance



after deductible


after deductible

Tier 5 – Preferred Specialty Drugs50% coinsurance



after deductible


after deductible

Tier 6 – Non-Preferred Specialty Drugs50% coinsurance



after deductible


after deductible


Language & Non-Discrimination NoticeConnectiCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.ConnectiCare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

ConnectiCare:• Provides free aids and services to people with disabilities to communicate

effectively with us, including qualified interpreters and information in alternate formats.

• Provides free language services to people whose primary language is not English, including translated documents and oral interpretation.

If you need these services, contact ConnectiCare’s Committee for Civil Rights.

If you believe that ConnectiCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: The Committee for Civil Rights, ConnectiCare, 175 Scott Swamp Road, Farmington, CT 06034, Phone: 1-800-251-7722, and TTY: 1-800-833-8134. You can file a grievance in person or by mail. If you need help filing a grievance, The Committee for Civil Rights is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Important information about the ConnectiCare® SOLO plans in this bookletConnectiCare SOLO is now guaranteed issue Guaranteed issue simply means that your SOLO health insurance policy will be issued regardless of your health status. There is no underwriting and there are no medical questions on the application.

EligibilityYou may apply for ConnectiCare SOLO if you meet the following criteria:

• Legal resident of Connecticut• Be under age 65• Not enrolled in Medicare• Single or married, or one of the following:

– Dependent spouse– Civil union/domestic partner*– Dependent child to age 26 who is not covered

under a group health plan

*Domestic partners must submit the Domestic Partner Verification Form or other satisfactory certification as we determine. CAUTION: Domestic partners are not recognized by the IRS as legal dependents for HSA funding. You should consult with your ConnectiCare agent and your tax advisor before establishing an HSA.

Renewal ProvisionWe can refuse to renew your active policy only when we refuse to renew all individual plans in this State. Nonrenewal will not affect an existing claim.

Eligibility Periods:Open EnrollmentFor 2017, Open Enrollment Period is November 1, 2016 through January 31, 2017.

If you enroll: Your coverage will be effective:

November 1, 2016 – December 15, 2016 January 1, 2017

December 16, 2016 – January 15, 2017 February 1, 2017

January 16, 2017 – January 31, 2017 March 1, 2017

Limited Open Enrollment:An individual can experience a qualifying event that makes him/her eligible to apply for health care coverage outside the Open Enrollment period. This is called a Special Enrollment Period. If you have experienced a qualifying event, you can apply for coverage within 60 days following the event. Examples of a Qualifying Event include:

• An individual and/or any dependents lose Minimum Essential Coverage (MEC) not resulting from failure to pay a premium or providing false information on a previous application

• An individual gains or becomes a dependent through birth, adoption, or placement for adoption

• An individual gains or becomes a dependent through marriage

• An individual gained a dependent through court order, including child support

• An individual experiences an error in enrollment• The divorce or legal separation that results in a loss

of group health coverage• A covered dependent loses group health coverage

because of a covered employee’s eligibility for Medicare

• A dependent child loses coverage due to loss of dependent status under an employee’s group health plan

• New coverage becomes available to an individual or enrollee that has permanently moved into the ConnectiCare service area

• A dependent loses coverage because of the death of a covered employee under a group plan

• The termination (other than for misconduct) or reduction of hours of a covered employee’s employment that results in a loss of group health coverage

12 chooseconnecticare.com

1 The Connecticut Mirror, 2015; HartfordBusiness.com, 2015; and Centers for Medicare & Medicaid Services (CMS) Monthly Summary Report (Data as of August 2016).2“Free” preventive care means that you will not have a copay or have to pay money toward your deductible or coinsurance for the services. Sometimes a preventive care visit leads to other medical care or tests, even at the same appointment. You should check with your doctor or doctor’s staff during your visit to see if there are services you may be billed for.3MDLIVE does not replace the primary care physician. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs, which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. MDLIVE interactive audio consultations with store and forward technology are available 24/7/365, while video consultations are available during the hours of 7 a.m. to 9 p.m., 7 days a week or by scheduled availability. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit www.mdlive.com/pages/terms.html. 4 Discount programs provide access to discounted tuition and are NOT insured benefits. These discounts are offered separate from your health benefits. These arrangements do not represent an endorsement or guarantee on the part of ConnectiCare, Inc. You are responsible for the full cost of the discounted tuition. Vendors such as Sage, LLC are independent contractors and are not agents of ConnectiCare Specialty Services. Vendor participation may change without notice. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Sage, LLC, refer to www.tuitionrewards.com/cci.

©2016 ConnectiCare, Inc. & Affiliates. SOLOPRODBROC 1016

Questions?

By phone: 1-800-723-2986 Monday - Friday, 8 a.m. to 5 p.m.,

or call your broker

In person: At a ConnectiCare center Online: chooseconnecticare.com

Documents

SOLO Product Options