2023 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
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.
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Drug Deductible
$0
Gap Coverage: In 2023, once you and your plan have spent $4,660 on covered drugs combined, you're in the Coverage Gap Stage where the 30 day supply costs: $0 for Tier 6 drugs and 25% of the cost for Part D generic and brand name drugs, plus a portion of the dispensing fee for Tiers 1-5.
Catastrophic Coverage: In 2023, once you've spent $7,400 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage where the 30 day supply costs: The greater of $4.15 for generic prescriptions, $10.35 for brand name prescriptions, or 5% of the prescription price.
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Tier 1 - Preferred Generic Drugs
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Initial Coverage Stage
$0 for 30 day retail supply; $0 for 90 day mail order supply
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Tier 2 - Non-Preferred Generic Drugs
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Initial Coverage Stage
$0 for 30 day retail supply; $0 for 90 day mail order supply
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Tier 3 - Preferred Brand Name Drugs
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Initial Coverage Stage
$47 for 30 day retail supply; $94 for 90 day mail order supply
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Tier 4 - Non-Preferred Drugs (includes Brand Name and Generic)
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Initial Coverage Stage
$100 for 30 day retail supply; $200 for 90 day mail order supply
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Tier 5 - Specialty Drugs
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Initial Coverage Stage
33% of cost for 30 day retail supply
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Tier 6 - Vaccines
$0
Plan Essentials
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Deductible
$0
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Maximum Out of Pocket
$4,900
Routine Doctor Visits and Checkups
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Primary Care Provider (PCP)
$0 per visit
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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
$0 per day for Lab Services
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Routine Vision Exam
$15 per annual visit
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Routine Hearing Exam
$0 per annual visit
Specialty Visits, Surgery, and Exams
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Specialist Copay
$45 per visit
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X-Rays
$30 per day
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Diagnostic Procedures
$30 per day
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Diagnostic Radiology Services
Ultrasound: $60 per day; Others: $250 per day
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Outpatient Surgery
Colonoscopies: $0; Others (ASC): $270 per day; Others (Non-ASC): $370 per day
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Physical, Occupational, and Speech Therapy
$30 per visit
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Cardiovascular Screening
$0 per annual visit
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Cancer Screening (Colorectal, Prostate, Breast)
$0 per annual visit
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Colonoscopy
$0
Unforeseen Care, Emergency Services, and Hospital Stays
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Urgent Care
PCP: $0; Specialist: $45 per visit; Urgent Care Center: $45 per visit.
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Emergency Room Visits
$90 per visit
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Inpatient Hospital Coverage
$475 per day for days 1-4; $0 per day for day 5 and beyond
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Ambulance Rides and Services
$300 per day
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).
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Individual Annual Deductible
$100 on Class 2 and 3 Services
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Calendar Year Maximum
The plan pays up to the calendar year maximum of $1,500.
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Periodic Oral Evaluation
$0 copay; Two per year.
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Comprehensive Oral Exam
$0 copay; Once every 36 months (includes the initial dental history and charting of teeth).
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Intra Oral Bitewing X-ray (X-rays of Crowns of Teeth)
$0 copay; Two per year (when oral conditions indicate need).
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Intra Oral X-ray - Entire Mouth (Panoramic & Full Mouth)
50% coinsurance after deductible; Once every 60 months.
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Single Tooth X-ray Images
50% coinsurance after deductible; As needed.
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Periodontal Cleaning
50% coinsurance after deductible; Once every 6 months following active periodontal therapy, not to be combined with regular cleanings
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Simple Extractions
50% coinsurance after deductible; Once per tooth.
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Surgical Extractions
50% after deductible; Once per tooth.
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Bridge or Denture Repair
50% coinsurance after deductible; Once every 24 months per bridge or denture.
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Dentures (Complete or Partial)
50% coinsurance after deductible; Once per arch within 84 months.
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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).
Benefits
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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.
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CarePerks 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).
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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.
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Over-The-Counter (OTC) Bonus
$50 every calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes. (Catalog + Retail)
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Acupuncture
$20 per visit
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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
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Eyewear Benefit
$150 annual allowance through EyeMed; $90 per calendar year for non-Eyemed provider.