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CarePartners

Access (PPO)

The CarePartners Access (PPO) Plan is our $0 premium plan, designed for those who want a low cost Medicare option without compromising on coverage or restrictions of a network. This plan gives you the freedom to access any doctor or hospital. Plan highlights:

  • $0 monthly premium which includes prescription drug coverage
  • $1,000 of dental coverage (for in- and out-of-network services)
  • $0 Tier 1 and Tier 2 Rx drugs, plus $0 Tier 6 vaccines
  • $50/quarter for over-the-counter health items
  • No referrals required

Questions about our PPO plan? Call now: 1-844-404-5251 (TTY: 711)

Have Questions? Call Now:

1-844-404-5251
(TTY: 711)

To see plans available in your area, please enter your zip code.

$0 per month
Enroll in this Plan
See what you can save:
Select a scenario below to see how your CarePartners Access PPO plan can save you more than Original Medicare.

Plan Essentials

Deductible

$1,000 combined in- and out-of-network

Maximum Out of Pocket Cost

$7,550 combined in- and out-of-network

Routine Doctor Visits and Checkups

PCP Co-Pay

INN: $0; OON: $20 per visit after deductible

Telehealth

Medicare-covered services plus additional telehealth services. Additional telehealth services include but are not limited to: primary care physician services, specialist services, individual sessions for mental health and psychiatric services, opioid treatment program services, observation services, and individual sessions for outpatient substance abuse. Applicable office visit costshare applies for non-opioid treatment program telehealth services. Opioid treatment program services cost-share applies to telehealth services rendered as part of an opioid treatment program services episode.

Cardiovascular Screening

INN: $0; OON: 30%

Cancer Screening (Colorectal, Prostate, Breast)

INN: $0; OON: 30%

Routine Vision Exam

INN: $0; OON: 30% after deductible

Eyewear Benefit

$150 allowance per calendar year

Routine Hearing Exam

INN: $0; OON: $50 per visit after deductible

Specialty Visits, Surgery, and Exams

Specialist Co-Pay

INN: $45 per visit; OON: $50 per visit after deductible

Physical, Occupational, and Speech Therapy

INN: $40 per visit; OON: 30% after deductible

Laboratory Services

INN: $0; OON: 30% after deductible

X-Rays

INN: $10 per day; OON: 30% after deductible

Diagnostic Tests

INN: $40 per day; OON: 30% after deductible

Diagnostic Radiology Services

INN: Ultrasound: $60 per day; Others: $250 per day; OON: 30% after deductible

Outpatient Surgery

INN: Colonoscopies: $0; Others: $250 per day after deductible; OON: 30% after deductible

Unforeseen Care, Emergency Services, and Hospital Stays

Urgent Care

$45 per visit

Ambulance Rides and Services

INN: $325 per one-way trip; OON: $325 per one-way trip after deductible

Emergency Room Visits

$90 per visit

Inpatient Hospital Coverage

INN: $795 per stay after deductible; OON: 30% per stay after deductible

Drugs and Drug Deductibles

Drug costs shown for Tier 1 and Tier 2 are reflective of Preferred Pharmacy pricing. Please use our Preferred Pharmacy Directory at carepartnersct.com/pharmacy to find a location near you.

Drug Deductible

$0

Tier 1

Initial Coverage Stage
$0 for 30 day retail supply; $0 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 2

Initial Coverage Stage
$0 for 30 day retail supply; $0 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 3

Initial Coverage Stage
$47 for 30 day retail supply; $94 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 4

Initial Coverage Stage
$100 for 30 day retail supply; $200 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 5

Initial Coverage Stage
33% of cost for 30 day retail or mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 6

Vaccines
$0

Benefits

Embedded Dental Benefits

$1,000 yearly maximum. $0 for preventive services such as cleanings and oral exams, 50% coinsurance for restorative services such as fillings and simple extractions, and 50% coinsurance for major services such as dentures, bridges, and crowns. No waiting period.

CarePerks Health & Wellness Allowance

Not Covered.

SilverSneakers Membership

INN: 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. OON: You pay $0 for at-home exercise kits.

Over-The-Counter (OTC) Bonus

$50 per calendar quarter to use towards covered OTC items. No rollover of unused calendar quarter balance. See Evidence of Coverage (EOC) for more information.

Hearing Aid Benefit

You are covered for up to 2 hearing aids per year, 1 aid per ear. Different copays apply.
$250 Standard Level
$475 Superior Level
$650 Advanced Level
$850 Advanced Plus Level
$1,150 Premier Level

Weight Management Programs

Not Covered.

Wellness Allowance

Not Covered.

Acupuncture

INN: $10 per visit; OON: $50 per visit after deductible

Embedded Dental Benefits

Members may see any licensed dentist. Out-of-pocket costs for out-of-network services may be higher than for services performed by providers in the Dominion PPO network. No waiting period. For more detailed plan information see your Evidence of Coverage (EOC).

Individual Annual Deductible

$0

Calendar Year Maximum

The plan pays up to the calendar year maximum of $1,000.

Periodic Oral Evaluation

$0 copay; Two per year.

Comprehensive Oral Exam

$0 copay; Once every 36 months (includes the initial dental history and charting of teeth)

Intra Oral Bitewing X-ray (X-ray of Crowns of Teeth)

$0 copay; Two per year (when oral conditions indicate need).

Intra Oral X-ray - Entire Mouth (Panoramic & Full Mouth)

50% coinsurance; Once every 60 months.

Single Tooth X-ray Images

50% coinsurance; As needed.

Silver Filling and White Fillings (Front Teeth)

50% coinsurance; Once every 24 months per surface per tooth.

Periodontal Cleaning

50% coinsurance; Once every 6 months (following active periodontal therapy, not to be combined with regular cleanings)

Simple Extractions

50% coinsurance; Once per tooth. 

Surgical Extractions

50% coinsurance; Once per tooth.

Bridge or Denture Repair

50% coinsurance; Once every 24 months per bridge or denture. 

Dentures (Complete or Partial)

50% coinsurance; Once per arch within 84 months.

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)

Deductible

$1,000 combined in- and out-of-network

Maximum Out of Pocket Cost

$7,550 combined in- and out-of-network

PCP Co-Pay

INN: $0; OON: $20 per visit after deductible

Cardiovascular Screening

INN: $0; OON: 30%

Cancer Screening (Colorectal, Prostate, Breast)

INN: $0; OON: 30%

Routine Vision Exam

INN: $0; OON: 30% after deductible

Eyewear Benefit

$150 allowance per calendar year

Routine Hearing Exam

INN: $0; OON: $50 per visit after deductible

Specialist Co-Pay

INN: $45 per visit; OON: $50 per visit after deductible

Physical, Occupational, and Speech Therapy

INN: $40 per visit; OON: 30% after deductible

Laboratory Services

INN: $0; OON: 30% after deductible

X-Rays

INN: $10 per day; OON: 30% after deductible

Diagnostic Procedures

INN: $40 per day; OON: 30% after deductible

Diagnostic Radiology Services

INN: Ultrasound: $60 per day; Others: $250 per day; OON: 30% after deductible

Outpatient Surgery

INN: Colonoscopies: $0; Others: $250 per day after deductible; OON: 30% after deductible

Urgent Care

$45 per visit

Ambulance Rides and Services

INN: $325 per one-way trip; OON: $325 per one-way trip after deductible

Emergency Room Visits

$90 per visit

Inpatient Hospital Coverage

INN: $795 per stay after deductible; OON: 30% per stay after deductible
Drug costs shown for Tier 1 and Tier 2 are reflective of Preferred Pharmacy pricing. Please use our Preferred Pharmacy Directory at carepartnersct.com/pharmacy to find a location near you.

Drug Deductible

$0

Tier 1

Preferred Generic Drugs
$0 for 30 day retail supply; $0 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 2

Non-Preferred Generic Drugs
$0 for 30 day retail supply; $0 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 3

Preferred Brand Name Drugs
$47 for 30 day retail supply; $94 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 4

Non-Preferred Drugs (includes Brand Name and Generic)
$100 for 30 day retail supply; $200 for 90 day mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Tier 5

Specialty Drugs
33% of cost for 30 day retail or mail order supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand or 5% of cost

Weight Management Programs

SilverSneakers Membership

INN: 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. OON: You pay $0 for at-home exercise kits.

Preventive Dental Allowance

Hearing Aid Benefit

You are covered for up to 2 hearing aids per year, 1 aid per ear. Different copays apply.
$250 Standard Level
$475 Superior Level
$650 Advanced Level
$850 Advanced Plus Level
$1,150 Premier Level