2023 Medicare Advantage Plan Benefit Details for the ConnectiCare Passage Plan 1 (HMO) - H3528-010-0

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2023 Medicare Advantage Plan Details
Medicare Plan Name:	ConnectiCare Passage Plan 1 (HMO)
Location:	Hartford, Connecticut Click to see other locations
Plan ID:	H3528 - 010 - 0 Click to see other plans
Member Services:	1-800-224-2273 TTY users 711
— This plan information is for research purposes only. — Click here to see plans for the current plan year
Medicare Contact Information:	Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance
Email a copy of the ConnectiCare Passage Plan 1 (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:	$0.00 (see Plan Premium Details below)
Annual Rx Deductible:	$150 (Tier 1, 2, 3 and 6 excluded from the Deductible.)
Annual Rx Initial Coverage Limit (ICL):	$4,660
Health Plan Type:	Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):	$7,550
Additional Rx Gap Coverage?	Yes, some additional gap coverage.
Total Number of Formulary Drugs:	3,559 drugs	Browse the ConnectiCare Passage Plan 1 (HMO) Formulary
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers.
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less.
Formulary Drug Details:	Tier 1	Tier 2	Tier 3	Tier 4	Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:	$2.00	$10.00	$42.00	$95.00	30%
• Number of Drugs per Tier:	229	909	782	805	734
Plan Offers Mail Order?	Yes
Medicare Plan Pharmacy Numbers:	BIN: 610014 PCN: MEDDPRIME See BIN/PCNs for all plans
Number of Members enrolled in this plan in Hartford, Connecticut:		2,241 members
Number of Members enrolled in this plan in Connecticut:		5,519 members
Number of Members enrolled in this plan in (H3528 - 010):		5,532 members
Plan’s Summary Star Rating:		3.5 out of 5 Stars.
• Customer Service Rating:		5 out of 5 Stars.
• Member Experience Rating:		3 out of 5 Stars.
• Drug Cost Accuracy Rating:		4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔	Total Premium	Part C Premium	Part D Basic Premium	Part D Supplemental Premium
The Monthly Premium is Split as Follows: ❔	$0.00	$0.00	$0.00	$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔		100% Subsidy	75% Subsidy	50% Subsidy	25% Subsidy
Monthly Part D Premium with LIS:		$0.00	$0.00	$0.00	$0.00
Total Monthly Premium with LIS (Parts C & D):		$0.00	$0.00	$0.00	$0.00

— Plan Health Benefits —
Base Plan
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: Yes
• Drug plan deductible: $150.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $7,550 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $0 copay
• Specialist: $45 copay per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $25 copay (authorization required)
• Lab services: $0-15 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $295 copay (authorization required)
• Outpatient x-rays: $45 copay (authorization required)
Emergency care/Urgent care
• Emergency: $95 copay per visit (always covered)
• Urgent care: $50 copay per visit (always covered)
Inpatient hospital coverage
• $490 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required)
Outpatient hospital coverage
• $475 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $275 copay
Rehabilitation services
• Occupational therapy visit: $40 copay
• Physical therapy and speech and language therapy visit: $40 copay
Mental health services
• Inpatient hospital - psychiatric: $1,871 per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist: $40 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $40 copay (authorization required)
• Outpatient group therapy visit: $40 copay (authorization required)
• Outpatient individual therapy visit: $40 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 10-20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: 20% coinsurance per item
Hearing
• Hearing exam: $45 copay
• Fitting/evaluation: $45 copay (limits apply)
• Hearing aids: $0 copay (limits apply)
Preventive dental
• Oral exam: Not covered
• Cleaning: Not covered
• Fluoride treatment: Not covered
• Dental x-ray(s): Not covered
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam: $45 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Not covered
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Some coverage
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Some coverage
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment: $45 copay
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: 10-20% coinsurance (authorization required)
• Other Part B drugs: 10-20% coinsurance (authorization required)
Package #1
• Monthly Premium: $16.00
• Deductible: $100.00
Package #2
• Monthly Premium: $30.00
• Deductible: N/A