2023 Access (PPO) Plan
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
- $65/quarter for over-the-counter health items
- No referrals required
Questions about our PPO plan? Call now: 1-844-404-5251 (TTY: 711)
Plan Essentials
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Deductible
$1,000 (combination of in and out-of-network costs)
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Maximum Out of Pocket
$4,900 for in-network providers; $8,950 for a combination of in and out-of-network costs
Routine Doctor Visits and Checkups
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Doctor Copay
In-Network: $0; Out-of-Network: $50 per visit after deductible
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Telehealth
In-Network: Includes Medicare covered services and additional telehealth services. $0 copay for e-visits and virtual visits. For all other telehealth visits, copay is the same as corresponding in-person visit copay.
Out-of-Network: Includes Medicare covered services; cost share is the same as corresponding in-person visit copay. Additional telehealth services not covered.
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Laboratory Services
In-Network: $0; Out-of-Network: 30% after deductible
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Routine Vision Exam
In-Network: $0 per annual visit; Out-of-Network $50 per annual visit after deductible
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Routine Hearing Exam
In-Network: $0 per annual visit; Out-of-Network: $50 per annual visit after deductible
Specialty Visits, Surgery, and Exams
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Specialist Copay
In-Network: $45 per visit; Out-of-Network: $50 per visit after deductible
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X-Rays
In-Network: $10 per day; Out-of-Network: 30% after deductible
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Diagnostic Procedures
In-Network: $40 per day; Out-of-Network: 30% after deductible
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Diagnostic Radiology Services
In-Network: Ultrasound: $60 per day; Others: $250 per day; Out-of-Network: 30% after deductible
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Outpatient Surgery
In-Network: Colonoscopy: $0; Others (ASC): $200 per day; Others (Non-ASC): $300 per daydeductible
Out-of-Network: 30% after deductible
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Physical, Occupational, and Speech Therapy
In-Network: $30 per visit; Out-of-Network: 30% after deductible
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Cardiovascular Screening
In-Network: $0; Out-of-Network: 30%
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Cancer Screening (Colorectal, Prostate, Breast)
In-Network: $0; Out-of-Network: 30%
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Colonoscopy
In-Network: $0; Out-of-Network: 30% after deductible
Unforeseen Care, Emergency Services, and Hospital Stays
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Urgent Care
$45 per visit
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Emergency Room Visits
$90 per visit
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Inpatient Hospital Coverage
In-Network: $795 per stay after deductible; Out-of-Network: 30% per stay after deductible
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Ambulance Rides and Services
In-Network: $325 per one-way trip; Out-of-Network: $325 per one-way trip after deductible
Benefits
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Embedded Dental Benefit
$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.
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CarePerks Health & Wellness Allowance
Not included.
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SilverSneakers Membership
In-Network: 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. Out-of-Network: You pay $0 for at-home exercise kits.
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Over-The-Counter (OTC) Bonus
$65 per calendar quarter to use towards covered OTC items. No rollover of unused calendar quarter balance. See Evidence of Coverage (EOC) for more information. (Catalog + Retail)
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Acupuncture
In-Network: $20 per visit
Out-of-Network: $50 per visit after deductible-
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 allowance per calendar year
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Weight Management Programs
Not Covered.
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Wellness Allowance
Not Covered.
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: $4.15 for generic prescriptions, $10.35 for brand name prescriptions or the greater of 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
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 $4.15 generic, $10.35 brand or 5% of cost
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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
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 $4.15 generic, $10.35 brand or 5% of cost
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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
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 $4.15 generic, $10.35 brand or 5% of cost
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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
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 $4.15 generic, $10.35 brand or 5% of cost
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Tier 5 - Specialty Drugs
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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 $4.15 generic, $10.35 brand or 5% of cost
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Tier 6 - Vaccines
$0
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).
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Individual Annual Deductible
$0
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Calendar Year Maximum
The plan pays up to the calendar year maximum of $1,000.
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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; Once every 60 months.
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Single Tooth X-ray Images
50% coinsurance; As needed.
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Silver Fillings and White Fillings (Front Teeth)
50% coinsurance; Once every 24 months per surface per tooth.
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Periodontal Cleaning
50% coinsurance; Once every 6 months (following active periodontal therapy, not to be combined with regular cleanings).
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Simple Extractions
50% coinsurance; Once per tooth.
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Surgical Extractions
50% coinsurance; Once per tooth.
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Bridge or Denture Repair
50% coinsurance; Once every 24 months per bridge or denture.
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Dentures (Complete or Partial)
50% coinsurance; Once per arch within 84 months.
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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).