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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.
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
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
Calendar Year Maximum
Periodic Oral Evaluation
Comprehensive Oral Exam
Intra Oral Bitewing X-ray (X-ray of Crowns of Teeth)
Intra Oral X-ray - Entire Mouth (Panoramic & Full Mouth)
Single Tooth X-ray Images
Silver Filling and White Fillings (Front Teeth)
Periodontal Cleaning
Simple Extractions
Surgical Extractions
Bridge or Denture Repair
Dentures (Complete or Partial)
Crowns and Onlays (Initial Placement)
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