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)

$0.00 per month
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Knee Replacement

John needs a knee replacement. He plans to have the surgery next year and wants to know how the costs will differ depending on his Medicare coverage. If he purchases the CarePartners of Connecticut CarePartners Access PPO Plan he can save $3,992 in-network.

Disclaimer

*All Medicare Only costs were calculated using the Healthcarebluebook.com "Fair Price" in Hartord, CT 06103 for 2020 and are for illustrative purposes only. Actual Original Medicare and CarePartners of Connecticut costs and services may vary.

CarePartners Access (PPO) (PPO) Original Medicare*
1 Primary Provider Visit $0 $45
1 Specialist Visit INN: $45 OON: $50 $45
1 X-Ray $10 $14
1 Knee Replacement Surgery INN: $795 after deductible OON: 30% after deductible $5,050
2 Day Post Surgery Hospital Stay INN: $1.590 OON: 30% after deductible $0
Medicare Part A Deductible $0 $1,408
10 Physical Therapy Visits INN: $400 OON: 30% after deductible $260
Pain Medication (Tier 1 Generic) $0 $10
Total INN: $2,840 OON: 30% after deductible $6,832

Estimated Savings On This Plan*

INN: $3,992

Broken Hip

Carol slipped on her front walkway and had to be rushed to the hospital in an ambulance. After being examined in the emergency room, she was told she had broken her hip and would require surgery. The chart shows how Carol can save $4,148 in-network on the CarePartners of Connecticut CarePartners Access PPO Plan versus Original Medicare alone.

Disclaimer

*All Medicare Only costs were calculated using the Healthcarebluebook.com "Fair Price" in Hartord, CT 06103 for 2020 and are for illustrative purposes only. Actual Original Medicare and CarePartners of Connecticut costs and services may vary.

CarePartners Access (PPO) (PPO) Original Medicare*
1 Emergency Room Visit $90 $274
1 X-Ray $10 $16
1 Hip Replacement Surgery INN: $795 after deductible OON: 30% after deductible $5,065
2 Day Hospital Stay INN: $1,590 OON: 30% after deductible $0
Medicare Part A Deductible $0 $1,408
10 Physical Therapy Visits INN: $400 OON: 30% after deductible $260
Pain Medication (Tier 1) 30 Day Supply $0 $10
Total INN: $2,885 ONN: 30% after deductible $7,033

Estimated Savings On This Plan*

INN: $4,148

High Blood Pressure

Elena is on Original Medicare and takes a number of medications to manage her high blood pressure. If she purchases a CarePartners of Connecticut CarePartners Access PPO plan she can save $1,666 in-network on her medications since Original Medicare alone doesn't include prescription drug coverage.

Disclaimer

*All Medicare Only costs were calculated using the Healthcarebluebook.com "Fair Price" in Hartord, CT 06103 for 2020 and are for illustrative purposes only. Actual Original Medicare and CarePartners of Connecticut costs and services may vary.

CarePartners Access (PPO) (PPO) Original Medicare*
12 Primary Care Provider Visits INN: $0 OON: $240 after deductible $540
Furosemide (Tier 1 Preferred Generic, 30 day supply) $0 $6
Torsemide (Tier 1 Preferred Generic, 30 day supply) $0 $9
Benicar (Tier 2 Non-Preferred Generic, 30 day supply) $0 $337
Bystolic (Tier 2 Non-Preferred Generic, 30 day supply) $0 $162
Edecrin (Tier 3 Preferred Brand Name, 30 day supply) $47 $458
Corgard (Tier 3 Preferred Brand Name, 30 day supply) $47 $164
Bumetanide (Tier 1 Preferred Generic, 30 day supply) $0 $18
Lab Services (6 Complete Blood Count Tests) INN: $0 OON: 30% after deductible $66
Total INN: $94 OON: 30% after deductible $1,760

Estimated Savings On This Plan*

INN: $1,666

Plan Essentials

Deductible

$1,000 combined in- and out-of-network

Maximum Out of Pocket

$7,550 combined in- and out-of-network

Routine Doctor Visits and Checkups

Doctor Copay

INN: $0; OON: $20 per visit after deductible

Laboratory Services

INN: $0; OON: 30% after deductible

Routine Vision Exam

INN: $0; OON 30% after deductible

Routine Hearing Exam

INN: $0; OON: $50 per visit after deductible

Specialty Visits, Surgery, and Exams

Specialist Copay

INN: $45 per visit; OON: $50 per visit 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

Physical, Occupational, and Speech Therapy

INN: $40 per visit; OON: 30% after deductible

Cardiovascular Screening

INN: $0; OON: 30%

Cancer Screening (Colorectal, Prostate, Breast)

INN: $0; OON: 30%

Colonoscopy

INN: $0; OON: 30% after deductible 

Unforeseen Care, Emergency Services, and Hospital Stays

Urgent Care

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

Ambulance Rides and Services

INN: $325 per one-way trip; OON: $325 per one-way trip after deductible

Benefits

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.

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

Eyewear Benefit

$150 allowance per calendar year

Weight Management Programs

Not Covered.

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.

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 $3.70 generic, $9.20 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 $3.70 generic, $9.20 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 $3.70 generic, $9.20 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 $3.70 generic, $9.20 brand or 5% of cost

Tier 5 - Specialty Drugs

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

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

$0

Calendar Year Maximum

The plan pays up to the calendar year maximum of $1,000.

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; Once every 60 months.

Single Tooth X-ray Images

50% coinsurance; As needed.

Silver Fillings and White Fillings (Front Teeth)

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

Periodontal Cleaning

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

Simple Extractions

50% coinsurance; Once per tooth. 

Surgical Extractions

50% coinsurance; Once per tooth.

Bridge or Denture Repair

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

Dentures (Complete or Partial)

50% coinsurance; Once per arch within 84 months.

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).