CareAdvantage

2022 Preferred (HMO) Plan

The CareAdvantage Preferred (HMO) Plan is our $0 premium plan, designed for those who want a low cost Medicare option without compromising on coverage. Plan highlights:

  • $0 monthly premium and $0 medical deductible
  • $1,500 of dental coverage—one of the state's leading dental benefits
  • $0 tier 6 vaccines, Rx deductible and select generic drugs
  • $325 CarePerks health and wellness allowance
  • Prescription drug coverage also included
  • No in-network referrals required
$0.00 per month
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Plan Essentials

Deductible

$0

Maximum Out of Pocket

$4,900

Routine Doctor Visits and Checkups

Doctor Copay

$0 per visit

Telehealth

$0 copay for e-visits and virtual check-ins;
For all other telehealth visits, copay is the same as corresponding in-person visit copay

Laboratory Services

FIT Tests: $0; Others: $5 per day

Routine Vision Exam

$15 per annual visit

Routine Hearing Exam

$45 per annual visit

Specialty Visits, Surgery, and Exams

Specialist Copay

$45 per visit

X-Rays

$10 per day

Diagnostic Procedures

$30 per day

Diagnostic Radiology Services

Ultrasound: $60 per day; Others: $250 per day

Outpatient Surgery

Colonoscopy: $0; Others: $350 per day

Physical, Occupational, and Speech Therapy

$40 per visit

Cardiovascular Screening

$0 per annual visit

Cancer Screening (Colorectal, Prostate, Breast)

$0 per annual visit

Colonoscopy

$0

Unforeseen Care, Emergency Services, and Hospital Stays

Urgent Care

PCP: $0; Specialist: $45 per visit

Emergency Room Visits

$90 per visit

Inpatient Hospital Coverage

$475 per day for days 1-4; $0 per day for day 5 and beyond

Ambulance Rides and Services

$300 per day

Benefits

Embedded Dental Benefit

$1,500 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. $100 deductible on restorative and major services. No waiting period.

CarePerks Health & Wellness Allowance

$325 CarePerks health and wellness allowance. ($150 reimbursement towards weight management programs like WeightWatchers, Jenny Craig, and hospital-based programs. $175 wellness benefit good towards a fitness tracker once every 3 years, a membership at a qualified health club or fitness facility, yoga classes, memory fitness and nutritional programs).

SilverSneakers Membership

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.

Over-The-Counter (OTC) Bonus

$25 every calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes.

Acupuncture

$20 per visit

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

 

Eyewear Benefit

$150 annual allowance through EyeMed

Weight Management Programs

See “CarePerks Health & Wellness Allowance” above.

Wellness Allowance

See “CarePerks Health & Wellness Allowance” above.

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 - Preferred Generic Drugs

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 $3.95 generic, $9.85 brand or 5% of cost

Tier 2 - Non-Preferred Generic Drugs

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 $3.95 generic, $9.85 brand or 5% of cost

Tier 3 - Preferred Brand Name Drugs

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 $3.95 generic, $9.85 brand or 5% of cost

Tier 4 - Non-Preferred Drugs (includes Brand Name and Generic)

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 $3.95 generic, $9.85 brand or 5% of cost

Tier 5 - Specialty Drugs

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 drugs

During Catastrophic Coverage Stage

The greater of $3.95 generic, $9.85 brand or 5% of cost

Tier 6 - Vaccines

$0

Embedded Dental Benefits

Access to thousands of dentists across the region. No waiting period. Services performed by providers in the Dominion PPO network and outside of the Dominion PPO network are covered. For more detailed plan information see your Evidence of Coverage (EOC).

Individual Annual Deductible

$100 on Class 2 and 3 Services

Calendar Year Maximum

The plan pays up to the calendar year maximum of $1,500.

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-rays 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 after deductible; Once every 60 months.

Single Tooth X-ray Images

50% coinsurance after deductible; As needed.

Silver Fillings and White Fillings (Front Teeth)

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

Periodontal Cleaning

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

Simple Extractions

50% coinsurance after deductible; Once per tooth. 

Surgical Extractions

50% after deductible; Once per tooth.

Bridge or Denture Repair

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

Dentures (Complete or Partial)

50% coinsurance after deductible; Once per arch within 84 months.

Crowns and Onlays (Initial Placement)

50% coinsurance after deductible; Once within 84 months per tooth (when teeth cannot be restored with regular filings due to fracture or decay).