Your ZIP Code spans multiple counties.
CareAdvantage
Prime (HMO)
The CareAdvantage Prime (HMO) Plan is designed for people looking for greater coverage at a lower cost. Plan highlights:
- $30 monthly premium which includes prescription drug coverage
- $0 medical deductible
- Lower copays for specialist visits and services
- Low out-of-pocket max
- No in-network referrals required
Have Questions? Call Now:
1-844-267-1361
(TTY: 711)
To see plans available in your area, please enter your zip code.
Plan Essentials
Deductible
$0
Maximum Out of Pocket Cost
$5,900
Routine Doctor Visits and Checkups
PCP Co-Pay
$0 per visit
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
$0 per annual visit
Cancer Screening (Colorectal, Prostate, Breast)
$0 per annual visit
Routine Vision Exam
$15 per annual visit
Eyewear Benefit
$150 annual allowance through EyeMed
Routine Hearing Exam
$40 per annual visit
Specialty Visits, Surgery, and Exams
Specialist Co-Pay
$40
Physical, Occupational, and Speech Therapy
$40
Laboratory Services
FIT Tests: $0; Others: $5 per day
X-Rays
$10 per day
Diagnostic Tests
$15 per day
Diagnostic Radiology Services
Ultrasound: $60 per day; Others: $250 per day
Outpatient Surgery
Colonoscopies: $0; Others: $275 per day
Unforeseen Care, Emergency Services, and Hospital Stays
Urgent Care
PCP: $0; Specialist: $40 per visit
Ambulance Rides and Services
$250 per day
Emergency Room Visits
$90 per visit
Inpatient Hospital Coverage
$375 per day for days 1-4; $0 per day for day 5 and beyond
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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name 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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name 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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name 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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name or 5% of cost
Tier 5
Initial Coverage Stage
33% of cost for 30 day retail supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name or 5% of cost
Tier 6
Vaccines
$0
Benefits
Embedded Dental Benefits
CarePerks Health & Wellness Allowance
Not included.
SilverSneakers Membership
You receive 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.
Over-The-Counter (OTC) Bonus
$40 every calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes.
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 Level
$1,150 Premier Level
Weight Management Programs
$150 Reimbursement. You are reimbursed up to $150 towards programs fees related to weight management programs like WeightWatchers, Jenny Craig, and hospital based programs.
Wellness Allowance
Not included.
Acupuncture
$10 per visit
Embedded Dental Benefits
Access to thousands of dentists across the region. No waiting period. Services must be performed by providers in the Dominion PPO network. Additional dental coverage is available for an additional $15 monthly premium. 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
$0
Maximum Out of Pocket Cost
$5,900
PCP Co-Pay
$0 per visit
Cardiovascular Screening
$0 per annual visit
Cancer Screening (Colorectal, Prostate, Breast)
$0 per annual visit
Routine Vision Exam
$15 per annual visit
Eyewear Benefit
$150 annual allowance through EyeMed
Routine Hearing Exam
$40 per annual visit
Specialist Co-Pay
$40
Physical, Occupational, and Speech Therapy
$40
Laboratory Services
FIT Tests: $0; Others: $5 per day
X-Rays
$10 per day
Diagnostic Procedures
$15 per day
Diagnostic Radiology Services
Ultrasound: $60 per day; Others: $250 per day
Outpatient Surgery
Colonoscopies: $0; Others: $275 per day
Urgent Care
PCP: $0; Specialist: $40 per visit
Ambulance Rides and Services
$250 per day
Emergency Room Visits
$90 per visit
Inpatient Hospital Coverage
$375 per day for days 1-4; $0 per day for day 5 and beyond
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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name 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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name 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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name 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 name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name or 5% of cost
Tier 5
Specialty Drugs
33% of cost for 30 day retail supply
During Coverage Gap Stage
25% of the cost of the brand name drugs; 25% of the cost of the generic name drugs
During Catastrophic Coverage Stage
The greater of $3.70 generic, $9.20 brand name or 5% of cost
Weight Management Programs
SilverSneakers Membership
You receive 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.
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 Level
$1,150 Premier Level