76962CT0010006-01 en US

Choice Gold Standard POS
Individual Market
Schedule of Benefits
Deductible and Out-of-Pocket IN-NETWORK (INET) OUT-OF-NETWORK (OON)
Maximum MEMBER PAYS MEMBER PAYS
Plan Deductible
Individual $1,250 per Member $3,000 per Member
Family $2,500 per Family $6,000 per Family
Separate Prescription Drug

Deductible
Individual $50 per Member $350 per Member
Family $100 per Family $700 per Family
Out-of-Pocket Maximum $4,400 per Member $8,800 per Member

(Includes deductible, copayments and $8,800 per Family $17,600 per Family
coinsurance)
Benefits IN-NETWORK (INET) OUT-OF-NETWORK (OON)

MEMBER PAYS MEMBER PAYS
Provider Office Visits
Adult Preventive Visit No cost 30% coinsurance per visit
Infant/Pediatric Preventive Visit No cost 30% coinsurance per visit
Primary Care Provider Office Visits $20 copayment per visit 30% coinsurance per visit after OON plan
(includes services for illness, injury, deductible is met
follow-up care and consultations)
Specialist Office Visits $40 copayment per visit 30% coinsurance per visit after OON plan
deductible is met
Mental Health and Substance Abuse $20 copayment per visit 30% coinsurance per visit after OON plan
Office Visit deductible is met
CBI/POS [HIX]/Gold/IND BS (01/2018) 76962CT0010006-01 Effective Date: 1/2018 1

Choice_Gold_St276140
Outpatient Diagnostic Services IN-NETWORK (INET) OUT-OF-NETWORK (OON)
Advanced Radiology $65 copayment per service up to a combined 30% coinsurance per service after OON plan
(CT/PET Scan, MRI) annual maximum of $375 for MRI and CAT deductible is met
scans; $400 for PET scans
Laboratory Services $10 copayment per service after INET plan 30% coinsurance per service after OON plan
deductible is met deductible is met
Non-Advanced Radiology $40 copayment per service after INET plan 30% coinsurance per service after OON plan
(X-ray, Diagnostic, Baseline deductible is met deductible is met
Mammography, Screening Tomosynthesis)
Mammography Ultrasound $20 copayment per service 30% coinsurance per service after OON plan
deductible is met
Prescription Drugs - Retail IN-NETWORK (INET) OUT-OF-NETWORK (OON)

Pharmacy MEMBER PAYS MEMBER PAYS
(30 day supply per prescription)
Tier 1 Prescription Drugs $5 copayment per prescription 30% coinsurance per prescription after OON
(Generic Drugs) prescription drug deductible is met
(Preferred Brand Drugs) prescription drug deductible is met
(Non-Preferred Brand Drugs) prescription drug deductible is met
Tier 4 Prescription Drugs 20% coinsurance up to a maximum of $100 per 30% coinsurance per prescription after OON
(Specialty Drugs) prescription after INET prescription drug prescription drug deductible is met
deductible is met
Prescription Drugs - Mail Order IN-NETWORK (INET) OUT-OF-NETWORK (OON)

(90 day supply per prescription) MEMBER PAYS MEMBER PAYS
Tier 1 Prescription Drugs $10 copayment per prescription Not covered

(Generic Drugs)

(Preferred Brand Drugs)

(Non-Preferred Brand Drugs)

Outpatient Rehabilitative and IN-NETWORK (INET) OUT-OF-NETWORK (OON)
Habilitative Services MEMBER PAYS MEMBER PAYS
Speech Therapy $20 copayment per visit 30% coinsurance per visit after OON plan
(40 visits per calendar year limit deductible is met
combined for Rehabilitative physical,
speech, and occupational therapies,
separate 40 visits per calendar year limit
combined for Habilitative speech, physical
and occupational therapies)
Physical and Occupational Therapy $20 copayment per visit 30% coinsurance per visit after OON plan
(40 visits per calendar year limit deductible is met
combined for Rehabilitative physical,
speech, and occupational therapies,
separate 40 visits per calendar year limit
combined for Habilitative speech, physical
and occupational therapies)
Other Services IN-NETWORK (INET) OUT-OF-NETWORK (OON)

Chiropractic Services $40 copayment per visit 30% coinsurance per visit after OON plan
(up to 20 visits per calendar year) deductible is met
Diabetic Equipment & Supplies 30% coinsurance per equipment/supply 30% coinsurance per equipment/supply after
OON plan deductible is met
Durable Medical Equipment (DME) 30% coinsurance per equipment/supply 30% coinsurance per equipment/supply after
OON plan deductible is met
Home Health Care Services No cost 25% coinsurance per visit after separate $50
(up to 100 visits per calendar year) deductible is met
Outpatient Services $500 copayment per visit after INET plan 30% coinsurance per visit after OON plan
(in a hospital or ambulatory facility) deductible is met deductible is met
Inpatient Hospital Services IN-NETWORK OUT-OF-NETWORK

Inpatient Hospital services $500 copayment per day up to a maximum of 30% coinsurance per visit after OON plan
(including mental health, substance $1,000 per admission after INET plan deductible is met
abuse, maternity, hospice and skilled deductible is met
nursing facility*)
*(skilled nursing facility stay is limited to
90 days per calendar year)

Emergency and Urgent Care IN-NETWORK OUT-OF-NETWORK
Ambulance Services No cost No cost
Emergency Room $200 copayment per visit $200 copayment per visit
Urgent Care Centers $50 copayment per visit 30% coinsurance per visit after OON plan
deductible is met
Pediatric Dental Care IN-NETWORK OUT-OF-NETWORK

(for children under age 20) MEMBER PAYS MEMBER PAYS
Diagnostic & Preventive No cost 50% coinsurance per visit after OON plan
deductible is met
Basic Services 20% coinsurance per visit 50% coinsurance per visit after OON plan
deductible is met
Major Services 40% coinsurance per visit 50% coinsurance per visit after OON plan
deductible is met
Orthodontia Services 50% coinsurance per visit 50% coinsurance per visit after OON plan
(medically necessary only) deductible is met
Pediatric Vision Care IN-NETWORK OUT-OF-NETWORK

(for children under age 20) MEMBER PAYS MEMBER PAYS
Prescription Eye Glasses Lenses: $0 Not covered

(one pair of frames and lenses or contact Collection frame: $0
lens per calendar year) Non-collection frame: Members choosing to
upgrade from a collection frame to a
non-collection frame will be given a credit
substantially equal to the cost of the collection
frame and will be entitled to any discount
negotiated by the carrier with the retailer
Routine Eye Exam by Specialist $40 copayment per visit 30% coinsurance per visit after OON plan
(one exam per calendar year) deductible is met

Adult Vision Care IN-NETWORK OUT-OF-NETWORK
(over age 20) MEMBER PAYS MEMBER PAYS
Routine Eye Exam by Specialist $40 copayment per visit 30% coinsurance per visit after OON plan
(one exam per calendar year) deductible is met
Important Information
1 This is a brief summary of benefits. Refer to your ConnectiCare Benefits, Inc. Policy for complete details on benefits, conditions, limitations
and exclusions. All benefits described are per member per Calendar year.
1 If you have questions regarding your plan, visit our website at www.connecticare.com or call us at (860) 674-5757 or 1-800-251-7722.
1 ConnectiCare offers a Telemedicine benefit for all members. The type of provider you see will determine the cost share and will follow
the PCP or Specialist office visit.
1 Out-of-Network reimbursement is based on the maximum allowable amount. Members are responsible to pay any charges in excess of this
amount. Please refer to your ConnectiCare Benefits, Inc. policy for more information.
1 Under this program covered prescription drugs and supplies are put into categories (i.e., tiers) to designate how they are to be covered and
the member's cost-share. The placement of a drug or supply into one of the tiers is determined by the ConnectiCare Pharmacy Services
Department and approved by the ConnectiCare Pharmacy & Therapeutics Committee based on the drugs or supplies clinical effectiveness
and cost, not on whether it is a generic drug or supply or brand name drug or supply.
1 Most specialty drugs are dispensed through specialty pharmacies by mail, up to a 30 day supply. Specialty Pharmacies have the same
Member Cost Share as all other participating pharmacies and are not part of ConnectiCare's Voluntary Mail Order Program. The Member
Cost Share for Specialty Pharmacy is different from the Cost Share for ConnectiCare's Mail Order program.

2018
CONNECTICARE BENEFITS, INC.
POINT OF SERVICE (POS) OPEN ACCESS
INDIVIDUAL EXCHANGE
POLICY
ConnectiCare Benefits, Inc.
175 Scott Swamp Road
Farmington, Connecticut 06032
WELCOME TO CONNECTICARE!
Thank you for choosing ConnectiCare. We look forward to providing you with the responsive customer service that our
Members have come to expect from us and working with you and your doctors to make sure you and your family make the right
choices to maximize the coverage available to you under this Plan.
IMPORTANT
Please read the “Managed Care Rules And Guidelines” section to learn this Plan’s rules. Understanding the rules of
this Plan will help you maximize your coverage. The “Managed Care Rules And Guidelines” section will explain how
this Plan operates and whether your Plan requires you to use Participating Providers, as well as whether you need to
obtain a Referral or Pre-Authorization before receiving care. In addition, please read the “Exclusions And Limitations”
section to find out what isn’t covered under this Plan.
RIGHT OF POLICY EXAMINATION
You are permitted to return this Policy by delivering or mailing it to the agent or broker through whom it was purchased, or to us
at the mailing address noted above within ten days after the date of delivery if, after examination of this Policy, you are not
satisfied with it for any reason. If you return this Policy, it will be deemed void from the beginning and any and all claims paid will
be retracted and any Premiums paid will be refunded.
GUARANTEED RENEWABLE
This Policy is guaranteed renewable provided the following requirements are satisfied:
• You continue to meet the eligibility requirements described in the “Eligibility And Enrollment” section of this Policy;
• You continue to pay the Premium due, as described in the “Premium Payment” section of this Policy; and
• Your membership has not been terminated, as described in the “Termination And Amendment” section of this Policy;
We may make changes to the benefits and/or Premium rates while this Policy is in effect:
• As described in the “Termination And Amendment” section of this Policy, or
• When renewed.
If we make any changes to the benefits, the changes apply to services that start on or after the Effective Date of this Policy
changes. These changes (including any decrease in benefits or removal of benefits) apply to:
• Any claims or expenses,
• Incurred services, or
• Supplies furnished.
There are no vested rights to receive any benefits described in this Policy after the date this Policy changes or terminates. This
applies even if the claim or expense took place after this Policy changes or ends but before you received the changed or new plan
documents.
Form: HIX CBI/POS OA IND 01 (1/2018)

Approved for use beginning 2018
s:/gmas/cbi exchange/2018/individual/2018 cbi ind exchange pos open access policy.doc
Take a look at the “Managed Care Rules And Guidelines” section to see if you need to obtain a Referral or have to use Participating Providers and the
“Pre-Authorization And Pre-Certification (Prior Approval) Addendum” to find out what services require Pre-Authorizations (prior approvals). Also
take a look at the “Exclusions And Limitations” section to find out what services are not covered under this Plan.
Page 1
2018 ConnectiCare Benefits, Inc. POS Open Access Individual Exchange Policy www.connecticare.com
IMPORTANT TELEPHONE NUMBERS AND ADDRESSES
Questions When Applying For Coverage Or Questions And Complaints

Determining Your Eligibility Or Premium Assistance ConnectiCare (general questions and complaints
And Cost-Share Reductions except for the Behavioral Health Program or the
Connecticut Health Insurance Exchange Connecticut Health Insurance Exchange)
(access health CT) ConnectiCare Member Services
(855) 805-4325 175 Scott Swamp Road
Farmington, Connecticut 06032 or
or
www.connecticare.com
Connecticut Health Insurance Exchange
450 Capitol Avenue, MS#52HIE Behavioral Health Program (Mental Health
Hartford, CT 06106-1379, or Services)
www.accesshealthct.com OptumHealth Behavioral Solutions
Attention: Complaints and Appeals Department
Member Services 1900 E. Golf Road. Suite 200
ConnectiCare Schaumburg, Illinois 60173
(860) 674-5757 or 1-800-251-7722 Fax 1-800-322-9104
TDD/TYY services Premium Payment Address
1-800-833-8134 ConnectiCare, Inc.
Behavioral Health Program (Mental Health PO Box 416191
Services) Boston, Massachusetts 02241-6191
1-888-946-4658
Dental (Pediatric Dental Services)
1-888-843-4727
Pre-Authorization or Pre-Certification
ConnectiCare
1-800-562-6833 Utilization management questions can be
asked from 8:00 a.m. to 5:00 p.m. Monday through
Friday and after hours, you may leave a voicemail
message.
Behavioral Health Program (Mental Health
Services)
1-888-946-4658
Radiology Services Program (Outpatient Diagnostic
X-rays And Therapeutic Procedures, Spine Surgery
And Interventional Pain Management)
1-877-607-2363
Submitting Claims to Us from Non-Participating
Providers
ConnectiCare (all claims except Behavioral Health
Program)
ConnectiCare Claims
PO Box 546
Farmington, Connecticut 06034-0546
Behavioral Health Program (Mental Health
Services)
ConnectiCare Claims
OptumHealth Behavioral Solutions
PO Box 30757
Salt Lake City, Utah 84130-0757
Page 2
INTRODUCTION
ATTENTION: If you speak a foreign language, language assistance services, free of charge, are available to you. Call 1-800-251-
7722 and TTY number 1-800-833-8134.
Spanish
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-251-7722 and
TTY number 1-800-833-8134.
Portuguese
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-251-7722 and TTY
number 1-800-833-8134.
Polish
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-251-7722 and
TTY number 1-800-833-8134.
Chinese
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-251-7722 and TTY number 1-800-833-
8134。
Italian
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il
numero 1-800-251-7722 and TTY number 1-800-833-8134.
French
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-251-
7722 and TTY number 1-800-833-8134.
French Creole
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-251-7722 and TTY number
1-800-833-8134.
Russian
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-xxx-xxx-xxxx
(телетайп: 1-800-251-7722 and TTY number 1-800-833-8134.
Vietnamese
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-251-7722 and TTY
number 1-800-833-8134.
Arabic
‫ )رق‬xxx-xxx-xxxx-1 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغویة تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ ملحوظة‬1-800-
251-7722 and TTY number 1-800-833-8134 :‫ھاتف الصم والبكم‬
Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-251-7722 and TTY number
1-800-833-8134번으로 전화해 주십시오.
Albanian
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-251-7722
and TTY number 1-800-833-8134.
Hindi
ध्यान द�: य�द आप �हद� बोलते ह �तो आपके ि◌लए मुफ्त म� भाषा सहायता सेवाएं उपलब्ध ह।� 1-800-251-7722 and TTY
number 1-800-833-8134 पर कॉल कर�।
Page 3
Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa 1-800-251-7722 and TTY number 1-800-833-8134.
Greek
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν.
Καλέστε 1-800-251-7722 and TTY number 1-800-833-8134.
Mon-Khmer, Cambodian
្រ◌បយ័ត�៖ េ◌េបើសិន�អ�កនិ�យ ��ែ◌ខ�រ, េ◌ស�ជំនួែយផ�ក�� េ◌�យមិនគិតឈ��ល គឺ�ច�នសំ�ប់បំេ◌រ�អ�ក។ ចូរ ទូរស័ព�1-800-251-7722 and TTY number 1-
800-833-8134 ។
Gujarati
��ુના: જો તમે �જરાતી બોલતા હો, તો િ◌ન:�લ્�ુ ભાષા સહાય સેવાઓ તમારા માટ� ઉપલબ્ધ છ. ફોન કરો 1-800-251-7722 and
TTY number 1-800-833-8134.
Page 4
MEMBERS’ RIGHTS AND RESPONSIBILITIES
YOUR RIGHTS
You have a right to:
• Receive information about us, our services, our Participating Providers, and Member’s Rights and Responsibilities,
• Be treated with respect and recognition of your dignity and right to privacy,
• Participate with practitioners in decision-making regarding your health care,
• A candid discussion of appropriate or Medically Necessary treatment options for your condition, regardless of cost or
benefit coverage,
• Refuse treatment and to receive information regarding the consequences of such action,
• Voice complaints or Appeals/Grievances about us or the care you are provided, and
• Make recommendations regarding our Member’s Rights and Responsibilities policies.
YOUR RESPONSIBILITIES
You have a responsibility to:
• Select a Primary Care Provider (PCP),
• Provide, to the extent possible, information providers need to render care and we need to provide coverage,
• Follow the plans and instructions for care that you have agreed on with practitioners,
• Keep scheduled appointments or give sufficient advance notice of cancellation,
• Pay the Copayments, Deductibles or Coinsurance,
• Follow the rules of this Plan, and assume financial responsibility for not following the rules,
• Understand your health problems and participate in developing mutually agreed upon treatment goals to the degree
possible,
• Be considerate of providers, and their staff and property, and respect the rights of other patients,
• Be considerate of our employees by treating them with respect and dignity, and
• Read this document describing this Plan’s benefits and rules.
Page 5
TABLE OF CONTENTS Take An Active Role.................................................... 16
Very Few Exceptions To The Use Of Participating
IMPORTANT TELEPHONE NUMBERS AND Providers ........................................................................ 16
ADDRESSES ................................................................ 2 Participating Provider Reimbursement Methods ... 16
INTRODUCTION ...................................................... 3 Non-Participating Providers For The Lower Level Of Benefits17
MEMBERS’ RIGHTS AND RESPONSIBILITIES.... 5 General Rules ................................................................ 17
Exceptions To The General Rules ............................ 17
YOUR RIGHTS ...........................................................................5 Non-Participating Provider Reimbursement Methods
YOUR RESPONSIBILITIES ........................................................5 ......................................................................................... 17
POLICY ........................................................................ 9 BENEFITS FOR STUDENTS, WHILE TRAVELING OR
ACCEPTANCE OF AGREEMENT ........................... 9 RESIDING TEMPORARILY OUT OF SERVICE AREA AND
CONNECTICARE ID CARD ..................................... 9 AFTER HOURS CARE ............................................................. 17
Students ................................................................................. 17
COVERAGE ................................................................. 9 Traveling Or Residing Temporarily Out Of Service Area ...... 18
ELIGIBILITY AND ENROLLMENT ....................... 9 After Hours Care .................................................................. 18
COST-SHARES YOU ARE REQUIRED TO PAY ................... 18
ELIGIBILITY RULES ..................................................................9
Amount Of In-Network Level Of Benefits ............................ 18
General Rules About You (The Subscriber) ..........................10
Amount Of Out-Of-Network Level Of Benefits .................... 18
General Rules About Your Eligible Dependents ....................10
Deductibles ............................................................................ 19
ADDING ELIGIBLE DEPENDENTS ......................................11
Plan Deductible ............................................................ 19
Adding A New Spouse .........................................................11
In-Network Level Of Benefits Plan Deductible 19
Adding New Children ...........................................................11
Out-Of-Network Level Of Benefits Plan
EFFECTIVE DATE OF COVERAGE .......................11
Deductible ................................................................. 19
GENERAL RULE......................................................................11 How Plan Deductibles Are Met ............................ 19
OPEN ENROLLMENT PERIODS ............................................11 Benefit Deductible ....................................................... 20
Annual Open Enrollment......................................................11 More About Deductibles ............................................ 20
Special Enrollment Period ......................................................12 Copayments ........................................................................... 20
Effective Date Of Special Open Enrollment Period Coinsurance ........................................................................... 20
..........................................................................................13 Maximums ............................................................................ 21
Special Effective Date Rules.......................................13 Benefit Maximums ....................................................... 21
WHEN A MEMBER IS AN INPATIENT AT THE TIME OF Out-Of-Pocket Maximums ........................................ 21
ELIGIBILITY ............................................................................13 In-Network Level Of Benefits Out-Of-Pocket
APPLICATION OF POLICY TO HEALTH SERVICES ...........13 Maximum .................................................................. 21
CHANGES AFFECTING ELIGIBILITY ...................................14 Out-Of-Network Level Of Benefits Out-Of-
ELIGIBILITY FOR ADVANCE PAYMENTS OF PREMIUM Pocket Maximum ..................................................... 21
TAX CREDIT OR REDETERMINATIONS OF ELIGIBILITY14 MEDICAL NECESSITY AND APPROPRIATE SETTING FOR
MANAGED CARE RULES AND GUIDELINES .... 14 CARE ........................................................................................ 22
SELECTION OF A PRIMARY CARE PROVIDER (PCP) .......14 UTILIZATION MANAGEMENT ............................................. 22
WHEN YOU NEED SPECIALIZED CARE .............................14 QUALITY ASSURANCE ........................................................... 22
SERVICES REQUIRING PRE-AUTHORIZATION OR PRE- NEW TREATMENTS................................................................ 23
CERTIFICATION ......................................................................14 EXPERIMENTAL OR INVESTIGATIONAL............................ 23
The Pre-Authorization Or Pre-Certification Process ..............14 Certain Investigational Items Outside Of Clinical Trials ....... 24
When Being Treated By A Participating Provider ..14 INSUFFICIENT EVIDENCE OF THERAPEUTIC VALUE ..... 24
When Being Treated By A Non-Participating DELEGATED PROGRAMS ...................................................... 24
Provider ..........................................................................14 BENEFITS ................................................................. 25
Changes To The Pre-Authorization Or Pre-Certification Lists PREVENTIVE SERVICES......................................................... 25
..............................................................................................15 Routine Medical Exams And Preventive Care ...................... 25
When Pre-Authorization Or Pre-Certification Is Denied.......15 Infants/Children........................................................... 25
Benefit Reduction ...................................................................15 Preventive Care Medical Services ......................... 25
Benefit Reduction Amounts .......................................15 Routine Eye Care ..................................................... 25
Benefit Reduction Exception .....................................15 Adults ............................................................................. 25
Expedited Review For Pre-Authorization Or Pre-Certification Preventive Care Medical Services ......................... 25
..............................................................................................15 Gynecological Preventive Exam Office Services25
USING PARTICIPATING PROVIDERS AND NON- Routine Eye Care ..................................................... 25
PARTICIPATING PROVIDERS ................................................16 Preventive Exams And Preventive Care Limitations
Always Use Participating Providers For The Highest Level Of ......................................................................................... 25
Coverage.................................................................................16 Pediatric Dental Care (Under Age 20) ................................. 25
Page 6
Pediatric Dental Care Exclusions And Limitations 26 Outpatient Mental Health And Alcohol And Substance Abuse
Routine Cancer Screenings......................................................28 Disorder Treatment ............................................................... 35
Blood Lead Screening Exams And Risk Assessments Other Behavioral Health Benefits .......................................... 35
..........................................................................................28 Chemical Maintenance Treatment ............................ 35
Lead Screening Exams ............................................28 Evidence-Based Maternal, Infant And Early
Risk Assessments .....................................................28 Childhood Home Visitation Services ....................... 35
Cervical Cancer Screening (Pap Tests) .....................28 Extended Day Treatment Programs ......................... 35
Colorectal Cancer Screenings .....................................28 Intensive, Family-Based And Community-Based
Mammogram Screenings .............................................28 Treatment Programs .................................................... 35
Prostate Screening ........................................................29 Other Home-Based Therapeutic Interventions For
Routine Cancer Screening Limitations .....................29 Children.......................................................................... 35
Other Preventive Services ........................................................29 Behavioral Health Exclusions And Limitations...... 35
Hearing Screenings .......................................................29 OTHER SERVICES ................................................................... 35
Immunizations ..............................................................29 Home Health Services............................................................ 35
Newborn Care ...............................................................29 Disposable Medical Supplies And Durable Medical Equipment
OUTPATIENT SERVICES ........................................................29 (DME), Including Prosthetics ............................................... 36
Allergy Testing.......................................................................29 Disposable Medical Supplies ...................................... 36
Chiropractic Services...............................................................29 Durable Medical Equipment (DME), Including
Gynecological Office Services ...................................................29 Prosthetics ..................................................................... 36
Laboratory Services ................................................................29 Disposable Medical Supplies And Durable Medical
Maternity Care Office Services ...............................................30 Equipment (DME), Including Prosthetics Exclusions
Outpatient Habilitative Therapy And Rehabilitative Therapy, And Limitations ............................................................ 37
Including Physical, Occupational and Speech Therapy ............30 Ostomy Supplies And Equipment ......................................... 37
Primary Care Provider Office Services ....................................30 Ostomy Supplies Limitations ..................................... 37
Radiological Services ...............................................................30 ADDITIONAL SERVICES ........................................................ 38
Specialist Office Services .........................................................30 Autism Services ..................................................................... 38
EMERGENT/URGENT CARE ................................................30 Birth To Three Program (Early Intervention Services) ........... 38
Ambulance/Medical Transport Services.................................30 Cardiac Rehabilitation........................................................... 38
Emergency Services......................................................30 Casts And Dressing Application ........................................... 38
Non-Emergency Services ............................................30 Clinical Trials ....................................................................... 38
Emergency Services .................................................................31 Corneal Pachymetry ............................................................... 39
Urgent Care/Walk-In Care ..................................................31 Craniofacial Disorders ........................................................... 39
Urgent Care....................................................................31 Diabetes Services.................................................................... 39
Walk-In Care .................................................................31 Education ....................................................................... 39
AMBULATORY SERVICES (OUTPATIENT) ...........................31 Prescription Drugs And Supplies .............................. 39
INPATIENT SERVICES ............................................................31 Drug Ingestion Treatment (Accidental) .................................. 40
Hospital Services ....................................................................31 Drug Therapy (Outpatient/Home) ........................................ 40
Pre-Certification Rules For Non-Emergencies .......31 Eye Care ............................................................................... 40
General Hospitalizations .............................................32 Diseases And Abnormal Conditions Of The Eye .. 40
Dental Anesthesia .................................................................32 Eyeglasses And Contact Lenses................................. 40
Mastectomy Services ...............................................................32 Genetic Testing ...................................................................... 40
Maternity Services ..................................................................32 Hospice Care ......................................................................... 41
Inpatient Services..........................................................32 Hospital Care ........................................................................ 41
Post-Discharge Benefits ..............................................32 Infertility Services ................................................................... 41
Optional Early Discharge Programs .........................32 Benefits........................................................................... 41
Testing for Bone Marrow .......................................................33 Rules ............................................................................... 42
Solid Organ Transplants And Bone Marrow Transplants .....33 Lyme Disease Services ........................................................... 42
Transplant Pre-Authorization Rules .........................33 Neuropsychological Testing ..................................................... 42
Donor Benefits..............................................................33 Nutritional Counseling .......................................................... 42
Transportation, Lodging And Meal Expenses For Nutritional Supplements And Food Products ........................ 42
Transplants.....................................................................33 Enteral Or Intravenous Nutritional Therapy .......... 42
Skilled Nursing And Rehabilitation Facilities ......................34 Modified Food Products For Inherited Metabolic
Skilled Nursing And Rehabilitation Facilities Diseases .......................................................................... 43
Limitations .....................................................................34 Other Specialized Formulas ....................................... 43
BEHAVIORAL HEALTH (MENTAL HEALTH SERVICES) ...34 Pain Management Services ..................................................... 43
Inpatient Mental Health Services ...........................................34 Renal Dialysis ....................................................................... 43
Inpatient Alcohol And Substance Abuse Disorder Services....34 Sleep Studies .......................................................................... 44
Page 7
Surgery And Other Care Related To Surgery.........................44 OTHER INSURANCE ............................................................... 62
Anesthesia Services.......................................................44 Automobile Insurance Policies................................................ 62
Breast Implants .............................................................44 Workers’ Compensation ........................................................ 62
Oral Surgery Services ...................................................44 Rights To Receive And Release Necessary Information .......... 63
Reconstructive Surgery ................................................44 Facility Of Payment............................................................... 63
Sterilization ....................................................................44 RIGHTS OF RECOVERY ......................................................... 63
Termination Of Pregnancy .........................................44 SUBROGATION AND REIMBURSEMENT ............................. 63
Telemedicine Services ..............................................................44 CLAIMS FILING, QUESTIONS AND
Wound Care Supplies ............................................................45 COMPLAINTS, AND APPEAL/GRIEVANCE
Wound Care Supplies for Epidermolysis Bullosa ...45 PROCESS ................................................................... 64
HEALTH MANAGEMENT PROGRAMS .................................45 CLAIMS FILING ....................................................................... 64
PRESCRIPTION DRUGS ..........................................................46 Bills From A Participating Provider...................................... 64
Benefits ..................................................................................46 Bills From A Non-Participating Provider ............................. 64
Additional Benefits ................................................................46 Payment To Custodial Parent ................................................ 64
Over-The-Counter (OTC) Medications ...................46 Claims For Emergency Services ............................................. 64
Specialty Drugs..............................................................46 If You Are Covered By Another Insurance Plan ................... 65
Guidelines ..............................................................................47 Refund To Us Of Overpayments ........................................... 65
Certain Prescription Drugs/Supplies Require Pre- QUESTIONS AND COMPLAINTS .......................................... 65
Authorization ................................................................47 APPEAL/GRIEVANCE PROCESS .......................................... 65
When A Participating Provider Writes A Medical Necessity Appeal ...................................................... 66
Prescription ...............................................................47 Internal Appeal Process .............................................. 66
When A Non-Participating Provider Writes A Urgent Care Appeals/Grievances ............................. 67
Prescription ...............................................................48 Behavioral Health Urgent Requests .......................... 67
Always Use Your ID Card ..........................................48 All Other Urgent Requests ......................................... 67
Pharmacy Network ................................................................48 Bypassing The Internal Appeal/Grievance Process67
Using A Participating Pharmacy ................................48 External Review And Expedited External Review 68
Using A Non-Participating Pharmacy.......................48 Administrative (Non-Medical Necessity) Appeal/Grievance . 68
Prescription Drug Programs ...................................................48 TERMINATION AND AMENDMENT .................. 69
Generic Substitution Program....................................48
Pay The Difference Waiver ....................................49 WHEN A MEMBER TERMINATES COVERAGE .................. 69
Tiered Cost-Share Program ........................................49 Effective Dates Of Termination ............................................. 69
Mandatory Drug Substitution Program ....................49 TERMINATION OF COVERAGE FOR OTHER REASONS .. 69
Mandatory Drug Limitations Program .....................50 AMENDMENT.......................................................................... 70
Voluntary Mail Order Program ..................................50 PREMIUM PAYMENT ............................................. 70
Clinically Equivalent Alternative Drugs Or Supplies GRACE PERIODS .................................................................... 70
Program ..........................................................................50 Standard Grace Period .......................................................... 71
Cost-Share Waiver Programs .................................................51 Advance Payment Of The Premium Tax Credit (APTC) Grace
Member Cost-Sharing ............................................................51 Period .................................................................................... 71
Benefit Limits ........................................................................51 GENERAL PROVISIONS ......................................... 71
Fill Or Refill Limit ........................................................51 DEFINITIONS .......................................................... 72
Lyme Disease Treatment Limit ..................................51
Prescription Drug Exclusions And Limitations .....................52 NON-DISCRIMINATION DISCLOSURE
Exception Review For A Non-Covered Clinically Appropriate ADDENDUM............................................................. 82
Drug ......................................................................................53 PATIENT PROTECTION AND AFFORDABLE
Expedited Review (Exigent Circumstances) ............53 CARE ACT (PPACA) ADDENDUM ......................... 83
Standard Review (Non-Exigent Circumstances).....53
PRIMARY CARE PROVIDERS (PCP)S ................................... 83
Prescription Drug General Conditions....................................53
PLAN DESCRIPTION ADDENDUM ..................... 83
EXCLUSIONS AND LIMITATIONS ....................... 54
PRE-AUTHORIZATION AND PRE-
OTHER INSURANCE, RIGHTS OF RECOVERY,
CERTIFICATION (PRIOR APPROVAL)
SUBROGATION AND REIMBURSEMENT .......... 62
ADDENDUM............................................................. 84
Page 8
POLICY If you call or write our Member Services Department, give
the representative your ID number, so that we can serve you
This Policy is our contract. You and your Eligible better.
Dependents must follow its terms and conditions to obtain
benefits for health care services. If you lose your ConnectiCare ID card, contact our Member
Services Department or visit our web site at
This Policy includes this document and the following www.connecticare.com to request a replacement.
documents.
• Exchange enrollment form, COVERAGE
The Exchange enrollment form and any other forms we
• Benefit Summary, and
request must be received by us before a Qualified Individual
• Riders and supplementary inserts, if any. can be considered a Member under this Plan.
No statement by you in your application shall void this You are responsible for providing to us information about
Policy or be used in any legal proceeding unless such yourself and your dependents that is complete, accurate and
application or an exact copy thereof is included in or true to the best of your knowledge and belief. Coverage is
attached to this Policy. being provided to you under this Plan on the basis that you
Please read your Benefit Summary for details regarding are a Qualified Individual and the information that you have
particular features of your Plan, such as Coinsurance, provided to us is truthful. If you make a fraudulent or
Deductibles, exclusions and limitations. intentional misrepresentation of a material fact, coverage
may be cancelled. In the event that there is a change in the
When we refer to words like “we” or “us,” we mean name(s), address, telephone number(s) or email address(es)
ConnectiCare. When we refer to “you,” we mean you, the that you have provided to us, you are responsible for telling
Subscriber. Words in this document that are in “Upper us as soon as possible about the change(s).
Case” have special meaning. You can find their meaning in
the “Definitions” section. The Exchange enrollment form and any other forms or
statements that we request, must be received and accepted by
This Policy replaces any agreement, contract, policy or us before the Qualified Individual will be considered for
program of the same coverage that we may have issued to membership under this Plan. We reserve the right to accept
you prior to the date we issued this Policy. It is written or deny requested coverage based on the completion of an
according to the laws of the State of Connecticut, including Exchange enrollment form by the Qualified Individual. A
rules, regulations or other standards set forth by the proof of insurability statement must be completed by the
Exchange and/or the State of Connecticut Insurance Qualified Individual. If additional information is requested
Department (Department). We have the right to make and is not received by us within 45 days of the request, the
changes to this Policy, but only with approval from the Qualified Individual may be asked to reapply. If a Qualified
Department. If we change this Policy, we will tell you about Individual is denied coverage under this Plan, he/she cannot
the change when it becomes effective. re-apply for coverage for up to 12 months, as determined by
We have the discretion to define and interpret the terms of us.
this Policy and determine eligibility for plan benefits in
accordance with our policies and procedures and in ELIGIBILITY AND ENROLLMENT
accordance with applicable state and federal law. ELIGIBILITY RULES
ACCEPTANCE OF AGREEMENT Your eligibility and the eligibility of your family members for
This means that you agree to all the provisions of this Policy, coverage in this Plan as Qualified Individuals are determined
including any Riders, when you receive Plan benefits, when by the Exchange.
you pay Premium to us for coverage under this Plan, and The Exchange will determine if you and your dependents can
maintain this Policy more than ten days after it is delivered to enroll in this Plan as a Qualified Individual. The Exchange
you. uses the following eligibility rules to make that
determination.
CONNECTICARE ID CARD
If you have any questions about enrollment, you may
Always carry your ConnectiCare ID Card and present it
contact the Exchange at the telephone number listed in
whenever you receive services at the doctor’s office, in an
the “Important Telephone Numbers And Addresses”
emergency room or Urgent Care Center, or at any other
section.
health care facility or pharmacy. You should use your ID
card when you receive prescriptions at Participating
Pharmacies.
Page 9
Citizenship The following rules apply to children:
The applicant (the person applying for coverage) must be:
• Natural Children. Your natural children can be
• A citizen of the United States, or covered.
• A national of the United States, or • Adopted Children. Children legally adopted by you
can be covered if they meet the rules for natural
• A non-citizen who is lawfully present in the United
children once the adoption is final. Before the
States, and reasonably expected to be a citizen,
adoption becomes final, a child can be signed up for
national, or a non-citizen who is lawfully present for
coverage when you become legally responsible for at
the entire benefit period
least partial support for the child.
Incarceration
The person applying for coverage must not be incarcerated • Step-Children. Your step-children who are the
(in prison), other than in prison pending the completion of natural or adopted children of your spouse, or
charges. children for whom your spouse is appointed legal
guardian, can be covered.
Residency
The person applying for coverage must reside or intend to • Guardianship. Children for whom you are appointed
reside in the Exchange Service Area of this Plan. the legal guardian can be covered.
• Handicapped Children. To continue to be covered
General Rules About You (The Subscriber) beyond the allowable age for dependent children, the
You (the Subscriber) are eligible for coverage under this Plan child must:
as a Qualified Individual because you are: ♦ Live in the Exchange Service Area of this Plan;
1. A resident of the Exchange Service Area of this Plan. and
2. Age 18 and over. ♦ Be unable to support himself/herself by working
because of a mental or physical handicap, as
3. Not eligible for or enrolled in Medicare at the time of the
certified by the child’s physician; and
application, and
Are not renewing in a different policy or contract of ♦ Be dependent on you or your spouse for support
insurance which would duplicate benefits of Medicare and care because he/she has a mental or physical
Part A or Medicare Part B. handicap; and
4. Listed as the applicant on the application. ♦ Have become handicapped and must have always
been handicapped while he/she would have been
5. Approved by the Exchange. able to be signed up for dependent children
coverage if he/she were not disabled.
General Rules About Your Eligible
Proof of the handicap and the child’s financial
Dependents
dependence must be given to us within 31 days of the
Your Eligible Dependents are eligible for coverage under this date when the child’s coverage would end under
Plan as Qualified Individuals if they are: another insurer’s plan, or when you enrolled under
1. Your spouse – Your spouse must have a legally valid this Plan if the handicap existed before you enrolled
existing marriage license or valid existing civil union as for coverage under this Plan. You must give us proof
accepted by the State of Connecticut, and your spouse that the child’s handicap and financial dependence
must live with you or in the Exchange Service Area of continue if we ask for such proof. We will not ask for
this Plan. proof more than once a year.
2. Your child – Your child may be eligible for coverage • Qualified Medical Child Support Orders. Special
under this Plan until the end of the last day of this Plan’s rules apply when a court issues a QMCSO requiring
Renewal Date that is after his/her 26th birthday as long as you to provide health insurance for your child.
his/her birthday is not the same day as the first day of the Enrollment may be required even in circumstances in
Renewal Date. If you child’s 26th birthday is the first day which the child was not previously enrolled in this
of this Plan’s Renewal Date, eligibility for coverage will Plan and might not otherwise be eligible for coverage.
end on that day. We will not require the children to live with you, but
they must live in the State of Connecticut in order to
be covered.
Page 10
ADDING ELIGIBLE DEPENDENTS EFFECTIVE DATE OF COVERAGE
Adding A New Spouse GENERAL RULE
1. If you get married, you must apply for coverage to add The payment of Premium and the Exchange enrollment
your new spouse to this Plan. Your spouse’s eligibility for form, and any other forms or statements the Exchange or we
coverage is subject to him/her being a Qualified need, must be received and accepted by the Exchange or us
Individual and our acceptance based on review of the before a Qualified Individual will be considered for
information on your new spouse’s Exchange enrollment membership under this Plan.
form and his/her meeting the Plan’s eligibility
Your right to coverage for you and your dependents is
requirements and our underwriting criteria. subject to the condition that all of the information you
2. Coverage for your new spouse will begin on his/her provide is true, correct and complete to the best of your
Effective Date. You are not required to wait until the knowledge and belief. In addition, you are responsible for
next open enrollment period to apply for coverage for providing notification of all name and address changes.
your new spouse.
This Policy will take effect on the Effective Date, subject to
Adding New Children the payment of Premium and the completion and acceptance
of the Exchange enrollment form. If not received, this Policy
Your newborn natural child is enrolled for coverage for the
will be deemed void, and we will not have any responsibility
first 61 days after birth when we are notified of the birth or
for all claims incurred by you or your dependents after that
receive a claim for the newborn. You will be responsible for
date. Premiums received by us after the last day of the grace
any additional Premium.
period will not be accepted. You must meet our eligibility
When our initial notification is a claim, your child’s coverage rules.
will end on day 62, unless you notify us that you want
to continue the newborn’s coverage. You will be OPEN ENROLLMENT PERIODS
responsible for any additional Premium, for the first 61 days,
regardless of your decision to continue coverage beyond day Annual Open Enrollment
61. An annual open enrollment period, as established by the
rules of the Exchange, is provided for Qualified Individuals
In some cases, we may receive a claim from another insurer and enrollees.
that covers your newborn. Coordination of benefit rules may
require that we pay the newborn’s claim. In that case, we During an open enrollment, Qualified Individuals may enroll
will enroll the newborn and pay claims as appropriate. You in a Qualified Health Plan (QHP), and enrollees may change
will be responsible for any Premium owed for a newborn QHPs according to rules established by the Exchange.
enrolled in this manner. Qualified Individuals are only permitted to enroll in a QHP,
If your daughter is covered under this Plan, her newborn or as an enrollee to change QHPs, during the annual open
child can receive coverage ONLY for the first 61 days after enrollment period or a special enrollment period when the
the child’s birth, unless you or your covered spouse becomes Qualified Individual has experienced a qualifying event.
the child’s legal guardian and you are signed up under this American Indians may move from one QHP to another
Plan. QHP once per month.
A newly adopted child, a child for whom you become the
legal guardian, and step-child must apply for coverage within
61 days of the date of the adoption (or the date on which
you or your spouse become at least partially legally
responsible for the adopted child’s support and
maintenance), or the date of your marriage to the step-child’s
parent, or the date you became the legal guardian.
Page 11
Special Enrollment Period 4. A Qualified Individual’s enrollment or non-enrollment in
a QHP is unintentional, inadvertent, or erroneous and is
A special enrollment period is a period during which a the result of the error, misrepresentation, or inaction of
Qualified Individual or enrollee who experiences certain an officer, employee, or agent of the Exchange or HHS,
qualifying events or changes in eligibility may enroll in, or or its instrumentalities as determined by the Exchange.
change enrollment in, a QHP through the Exchange, or When this occurs, the Exchange may take action, as may
another individual plan outside of the Exchange. be necessary, to correct or eliminate the effects of the
A Qualified Individual or enrollee has 60 days from the error, misrepresentation or inaction.
date of one of the following triggering events to select 5. An enrollee adequately demonstrates to the Exchange
this Plan. that the QHP in which he/she is enrolled substantially
The Exchange will allow individuals to enroll in or change violated a material provision of its contract in relation to
from one QHP to another as a result of the following the enrollee.
triggering events: 6. An individual is determined newly eligible for advance
1. A Qualified Individual or dependent loses Minimum payments of Premium tax credit or has a change in
Essential Coverage. eligibility for Cost-Sharing reductions, regardless of
Loss of Minimum Essential Coverage includes loss of whether the individual is already enrolled in a QHP. The
eligibility for coverage as a result of: Exchange will permit individuals whose existing coverage
through an eligible employer-sponsored plan will no
• Legal separation or divorce, longer be affordable or provide minimum value for
• Cessation of dependent status, such as attaining the his/her employer’s upcoming plan year to access this
maximum age, special enrollment period prior to the end of his/her
coverage through such eligible employer-sponsored plan.
• Death of a Subscriber, or
7. A Qualified Individual or enrollee gains access to a new
• Any loss of eligibility for coverage after a period that QHP as a result of a permanent move where the
is measured by reference to any of the following: Qualified Individual or enrollee was enrolled in Minimum
♦ Individual who no longer resides in the Exchange Essential Coverage for one or more days preceding the
Service Area for this Plan, and date of the permanent move. Individuals previously living
outside the United States (U.S.) or in a U.S. territory and
♦ A situation in which a plan no longer offers any
individuals who are released from incarceration are not
benefits to the class of similarly situated
required to have any previously enrolled in Minimum
individuals that includes the individual.
Essential Coverage.
Loss of Minimum Essential Coverage does not include
8. An American Indian, as defined by federal regulation,
termination or loss due to:
may enroll in a QHP or change from one QHP to
• Failure to pay Premiums on a timely basis, or another one time per month.
• Situations allowing for a rescission such as fraud or 9. An American Indian, as defined by federal regulation,
intentional misrepresentation of material fact. who is a dependent of an American Indian, as defined by
2. A Qualified Individual gains a dependent or becomes a federal regulation, and is enrolled or is enrolling in a
dependent through: QHP through the Exchange on the same application as
the Indian, may change from one QHP to another QHP
• Birth, one time per month, at the same time as the Indian.
• Adoption, 10. A Qualified Individual or enrollee demonstrates to the
• Placement for adoption, Exchange that he/she meets other exceptional
circumstances as the Exchange may provide.
• Placement for foster care,
11. A Qualified Individual or enrollee experiences any
• Marriage, COBRA qualifying event.
• Child support order, or 12. An individual has a non-calendar year plan and that plan
• Other court order ends.
3. An individual, who was not previously a citizen, national, 13. A Qualified Individual who is the victim of domestic
or lawfully present individual gains such status. abuse or spousal abandonment as defined by federal
regulations, including a dependent on the same
application, or unmarried victim within a household, who
is enrolled in Minimum Essential Coverage and seeks to
enroll in coverage separate from the person who caused
the abuse or abandonment.
Page 12
14. A Qualified Individual or enrollee who applies for Special Effective Date Rules
coverage on the Exchange during the annual open In the case of birth, adoption, placement for adoption,
enrollment period or due to a qualifying event, and is placement for foster care, a child support order or other
assessed by the Exchange as potentially eligible for court order, the individual may select an Effective Date as of
Medicaid or the Children’s Health Insurance Program the date as of the birth, adoption, placement for adoption
(CHIP), but is determined ineligible for Medicaid or placement for foster care, a child support order or other
CHIP by the state Medicaid or CHIP agency either after court order or the 1st of the month following the date of the
the open enrollment period has ended or more than 60 birth, adoption, placement for adoption, placement for foster
days after the qualifying event. care, child support order or other court order, or a regular
15. A Qualified Individual who applies for coverage at the Effective Date as described in the “Effective Date Of Special
state Medicaid or CHIP agency during the open Open Enrollment Period” subsection, above.
enrollment period and demonstrates that they have been
In the case of marriage, or where a Qualified Individual loses
determined to be ineligible for Medicaid or CHIP after
Minimum Essential Coverage., as described in paragraph 1 of
the open enrollment period has ended.
this “Special Enrollment Period” subsection, the Effective
16. A Qualified Individual or enrollee, or his or her Date will be on the 1st day of the following month.
dependent, adequately demonstrates to the Exchange that
a material error related to plan benefits, Service Area or In the case of a permanent move, the Effective Date is the
Premium influenced the Qualified Individual’s or 1st of the month following the move if Plan selection is made
enrollee’s decision to purchase a QHP through the on or before the day of the move.
Exchange. Where the death of a Subscriber or Eligible Dependent
17. At the option of the Exchange, the Qualified Individual results in a Special Enrollment Period, the Effective Date is
provides evidence to verify his or her eligibility for an the 1st of the month following Plan selection or a regular
insurance affordability program or enrollment in a QHP Effective Date as described in the “Effective Date Of Special
through the Exchange following termination of Open Enrollment Period” subsection, above.
Exchange enrollment due to a failure to verify such status
within the time period specified in the federal regulations,
WHEN A MEMBER IS AN INPATIENT AT THE
or who is under 100% of the federal poverty level and did TIME OF ELIGIBILITY
not enroll in coverage while waiting for the U.S. If you or your covered dependents become eligible for
Department of Health and Human Services to verify his coverage under this Plan while an inpatient at a Hospital,
or her citizenship, status as a national, or lawful presence Hospice, Skilled Nursing Facility, Rehabilitation Facility or
Residential Treatment Facility, the coverage under this Plan
Effective Date Of Special Open Enrollment Period will be effective, but this Plan will not cover the costs of that
When the Exchange receives the Qualified Individual’s Hospitalization or inpatient stay or any medical care relating
selection to enroll in this Plan between the 1st and the 15th of to that Hospitalization or inpatient stay if these costs are the
the month, the Effective Date for coverage is the 1st day of responsibility of a previous carrier. You should notify us
the month following the date the Exchange receives a when an inpatient stay under these circumstances occurs.
Qualified Individual’s selection to enroll in this Plan.
For example, when a completed Exchange enrollment form APPLICATION OF POLICY TO HEALTH
is received and accepted by the Exchange on May 14th, the SERVICES
Qualified Individual’s Effective Date will be June 1st. This Policy replaces the prior policy or agreement, if any,
When the Exchange receives the Qualified Individual’s between you and us. This Policy applies to health care
selection to enroll in this Plan between the 16th and the last services rendered on and after the Effective Date of this
day of the month, the Effective Date for coverage is the 1st Policy. Medically Necessary health services and supplies are
day of the 2nd month following the date the Exchange not covered if the patient is not enrolled as a Member under
receives a Qualified Individual’s selection to enroll in this this Plan at the time the service or supply is rendered or
Plan. received.
For example, when a completed Exchange enrollment form

is received and accepted by the Exchange on May 16th, the
Qualified Individual’s Effective Date will be July 1st.
Page 13
CHANGES AFFECTING ELIGIBILITY MANAGED CARE RULES AND
You, or your authorized representative, must tell us or the GUIDELINES
Exchange about any change that may affect you or your
dependents covered under this Plan within 31 days of the SELECTION OF A PRIMARY CARE PROVIDER
date of that change. Examples of such changes are: (PCP)
Each Member should pick a PCP for routine physicals and
• Marriage,
to help when you are ill or need follow-up care after you
• Divorce or end of civil union, receive Emergency Services.
• Birth of your child or of a child of your daughter Each Member can pick a different PCP.
• Child reaching maximum age limit for coverage under If a Member does not pick a PCP at enrollment, we will pick
this Plan, one. We will tell you after we make that PCP selection.
• Change of home address, and A Member can change PCPs at any time by calling or writing
• Loss of eligibility for other reasons specified in this our Member Services Department or by visiting us at our
document web site at www.connecticare.com.
Changes should be indicated on an Exchange enrollment If your current PCP leaves our network of Participating
form at www.accesshealthct.com. You must return the Providers or will no longer treat patients at a certain office
Exchange enrollment form to your broker or to the where you may have received care, we will tell you about that
Exchange. change 30 days before it happens, if possible, or as soon as
possible after we become aware of the change. You will then
ELIGIBILITY FOR ADVANCE PAYMENTS OF have to pick a new PCP.
PREMIUM TAX CREDIT OR
REDETERMINATIONS OF ELIGIBILITY WHEN YOU NEED SPECIALIZED CARE
You should contact the Exchange for information about Members ARE NOT required to get a pre-approval
your eligibility for Advance Payments Of Premium Tax (referral) to see a specialist.
Credit or Redeterminations of your eligibility and that of When a Member sees a Specialist Physician regularly and that
your Eligible Dependents. Specialist Physician is no longer participating with us as a
part of our network of Participating Providers, we will tell
The Exchange telephone number is listed in the
you about that change 30 days before it happens, if possible,
“Important Telephone Numbers And Addresses”
or as soon as possible after we become aware of the change.
section.
Please call your PCP or check our Provider Directory for
help in selecting a new Specialist Physician.
SERVICES REQUIRING PRE-AUTHORIZATION

OR PRE-CERTIFICATION
The Pre-Authorization Or Pre-Certification
Process
When Being Treated By A Participating Provider
Participating Providers must get Pre-Authorization or Pre-
Certification of certain services, supplies or drugs when they
are treating a Member before the Member gets that service,
supply or drug.
When Being Treated By A Non-Participating Provider
If a Member is being treated by a Non-Participating
Provider, the Non-Participating Provider will often times
send us a request for Pre-Authorization or Pre-Certification
for those services, supplies or drugs that need it, BUT IT IS
YOUR RESPONSIBILITY TO MAKE SURE THAT
WE HAVE GIVEN PRE-AUTHORIZATION OR
PRE-CERTIFICATION BEFORE THE SERVICES
HAVE BEEN RENDERED.
Page 14
You must call the appropriate telephone number listed Benefit Reduction Amounts
in the “Important Telephone Numbers and Addresses” When a Non-Participating Provider arranges an admission to
subsection of the “Important Information” section to a Hospital or other facility for you or your Eligible
request Pre-Authorization or Pre-Certification. Dependents, or any of the services or supplies listed in the
You can find the list of Health Services that need Pre- “Services Requiring Pre-Certification Or Pre-Authorization”
Certification or Pre-Authorization at the back of this addendum are rendered by a Non-Participating Provider,
document. coverage for that admission and/or those services or
supplies will be reduced as follows if you did not obtain Pre-
Changes To The Pre-Authorization Or Pre- Certification or Pre-Authorization:
Certification Lists
• The lesser of $500 or 50% of the Maximum
Our Pre-Authorization or Pre-Certification lists may change Allowable Amount we will pay per admission and/or
at any time. Read the member newsletter to learn about the service or supply, as applicable.
changes. You can also contact our Member Services
Department or visit our web site at www.connecticare.com. Note: These Benefit Reductions are in addition to the
benefits that would normally be paid if proper Pre-
When Pre-Authorization Or Pre-Certification Certification or Pre-Authorization was obtained. Benefit
Is Denied Reductions do not apply to Emergency Services.
No benefits will be provided if a Member receives services or Benefit Reductions apply to the Out-Of-Network Level Of
supplies after Pre-Authorization or Pre-Certification has Benefits. All Benefit Reductions are your financial
been denied. responsibility.
If you fail to comply with the Pre-Authorization or Pre- Benefit Reduction Exception
Certification requirements of this Plan, there will be a Benefit If you or your Eligible Dependents are admitted to a
Reduction or, in some cases, a denial of benefits. The only Participating Hospital or other facility that is a Participating
time this won’t happen is in those instances where we say it Provider by a doctor that is a Non-Participating Physician,
is the responsibility of the Participating Provider to request you will not be responsible for the Benefit Reduction if you
Pre-Authorization or Pre-Certification. In those instances, failed to obtain Pre-Certification for that admission, as long
benefits will not be reduced or denied if the Participating as that admission was Medically Necessary. The Benefit
Provider fails to request Pre-Authorization or Pre- Reductions are in addition to the benefits that would
Certification. normally be paid if proper Pre-Authorization was obtained.
If you receive an explanation of benefits stating a claim was Benefit Reductions do not apply to Emergency Services.
denied where it was the responsibility of the Participating
Provider to request the applicable Pre-Authorization or Pre-
Expedited Review For Pre-Authorization Or
Certification, you should contact our Member Services Pre-Certification
Department, so we can help you resolve the issue. When a doctor must obtain Pre-Authorization or Pre-
Certification for a Hospital stay or for a health care treatment
Benefit Reduction while a Member is sick or injured and in the Hospital, the
As mentioned, when you use Non-Participating doctor may request an “Expedited Review” of the doctor’s
Providers to order, arrange, or provide your care, IT IS request in the following circumstances.
YOUR RESPONSIBILITY TO OBTAIN PRE- 1. You must already be admitted to a Participating Hospital
AUTHORIZATION OR PRE-CERTIFICATION for and your physician must have determined your life will be
the services or your benefits will be reduced or denied. endangered or that other serious injury or illness could
Your benefits will be denied if the services you or your occur if you are discharged from the Hospital or if the
Eligible Dependents obtained without Pre-Authorization or treatment in question is delayed.
Pre-Certification were not Medically Necessary or were not 2. Your attending physician must make a request for an
covered by this Plan. Expedited Review by telephoning the appropriate
If the services you obtained without the Pre-Authorization number designated for Expedited Reviews. If your
or Pre-Certification were Medically Necessary and otherwise doctor is unable to make contact by calling that number,
covered by this Plan, then your benefits will be reduced as he/she may leave a voice-mail message at the designated
described below. We call this a “Benefit Reduction.” alternative number(s).
3. If no additional information is required than what your
doctor provided with his/her request for the Expedited
Review, a decision will be made within three hours from
the time the initial request was made. If this three-hour
deadline is not met, the Expedited Review request will be
deemed approved.
Page 15
4. If additional information is requested to make a decision Very Few Exceptions To The Use Of Participating
that decision will be made within three hours from the Providers
time all the necessary additional information was sent to Generally, to be covered at the In-Network Level Of
complete the review. If this three-hour deadline is not Benefits, all health care services and supplies must be
met, the Expedited Review request will be deemed ordered, provided and supplied by a Participating Provider,
approved. even if you believe that a Non-Participating Provider is
5. If the Expedited Review request is approved on the initial “better” or you prefer to use a Non-Participating Provider.
telephone call, an authorization number will be given.
The very few exceptions are:
6. If the Expedited Review request is not approved, you and
your physician will have the Appeal/Grievance process • Emergency Services.
available to you, as described in this document. • Urgent Care.
7. Your attending physician must provide at least two • If we or, as appropriate, our Delegated Program,
methods of communication for responding to his/her issue(s) you written Pre-Authorization to use a Non-
request. Participating Provider before you obtain the service
8. Reviewing staff will be available from 8:00 a.m. to 9:00 or supply.
p.m. to process Expedited Review requests. Except as noted above, even if you or your Eligible
9. The three-hour time period will not apply to Expedited Dependents reside or travel outside of the Service Area
Review requests initiated between 6:00 p.m. and 8:00 a.m. for an extended length of time (e.g., you have a seasonal
residence in another state), services or supplies will not
USING PARTICIPATING PROVIDERS AND NON- be covered at the In-Network Level Of Benefits if they
PARTICIPATING PROVIDERS are received from Non-Participating Providers.
If you use Participating Providers for your care, you will be Participating Provider Reimbursement Methods
eligible for the highest level of benefits under this Plan. This The amount we pay Participating Providers for covered
is called the “In-Network Level Of Benefits.” Health Services, before any deduction of any applicable risk
If you use Non-Participating Providers to order, arrange or withholds, may include:
provide you your care, then you will be eligible for a lower • Fee for service (payment for each particular service);
level of benefits, called the “Out-Of-Network Level Of
Benefits.” • Per diem rates (payment of daily rates for each
inpatient day);
Review your Benefit Summary for the applicable Cost-
• Scheduled charges (payment of a fixed amount for
Share amounts of this Plan, any maximums this Plan
each particular service);
may have, and per calendar year or per Contract Year
coverage. • Capitated charges (payment of a fixed amount each
month per Member for specific services regardless of
Always Use Participating Providers For The the actual number of services provided); or
Highest Level Of Coverage • Other pricing mechanisms.
Use your Provider Directory, visit us at our web site at
www.connecticare.com, or call us for a list of Participating Participating Providers may tell a Member who asks the
Providers. Providers may end their participation with us for method we use to pay them.
different reasons, so check to make sure your provider is
currently participating in our network of Participating
Providers before obtaining care.
You can check the professional qualifications of Participating
Providers by calling us or by visiting our web site at
www.connecticare.com.
Take An Active Role
Ask your Participating Provider to refer you to Participating
Providers. Ask that any laboratory or radiology analysis
done on your behalf be sent to laboratories or facilities that
are Participating Providers.
Page 16
Non-Participating Providers For The Lower We reserve the right to deny authorization for In-Network
Level Of Benefits when the services or supplies rendered by
Level Of Benefits a Non-Participating Provider. In those limited circumstances
General Rules when authorization of services or supplies are to be paid at
If you use Non-Participating Providers for your care, then the In-Network Level Of Benefits, our authorization may
you are eligible to receive a lower level of benefits, called the impose limits and also determine which Non-Participating
“Out-Of-Network Level Of Benefits.” Provider will be used for the Health Services authorized.
In addition, if you use Non-Participating Providers for Non-Participating Provider Reimbursement Methods
your care, then IT IS YOUR RESPONSIBILITY to The rate we pay for covered Health Services provided by
request Pre-Authorization or Pre-Certification before Non-Participating Providers may vary according to the
you obtain care. provider used or the services received. Some Non-
Participating Providers may agree to give us a discounted rate
Exceptions To The General Rules
through negotiation with either us or a third party vendor.
When you obtain care for an Emergency or Urgent Care, you For others, payment may be based on the Non-Participating
obtain the In-Network Level Of Benefits even if you use a Provider’s billed charges or the amount we would pay a
Non-Participating Provider. Participating Provider. Professional fees paid to Non-
In addition, in very limited circumstances, if we determine Participating Providers are based on a percentage of what
Medically Necessary services are not reasonably available Medicare would pay.
from a Participating Provider, you can obtain the higher, In-
Network Level Of Benefits for care received from a Non- BENEFITS FOR STUDENTS, WHILE TRAVELING
Participating Provider. But to do that, you will need OR RESIDING TEMPORARILY OUT OF SERVICE
written Pre-Authorization BEFORE you obtain the care AREA AND AFTER HOURS CARE
from the Non-Participating Provider. Coverage is available at the In-Network Level Of Benefits
Pre-Authorization to obtain care from a Non-Participating when your children are away at school or you or your
Provider at the In-Network Level Of Benefits will be given Eligible Dependent child is traveling, temporarily out of the
only if both of the following conditions are met: Service Are or after your doctor has left for the day.
• The requesting Participating Provider is in the same Students
specialty as the Non-Participating Provider whose Coverage is available at the In-Network Level Of Benefits
services are requested, AND for your Eligible Dependent student while he/she is at
• We or, as appropriate, our Delegated Program have school (outside of the Service Area), as long as you obtain
determined Medically Necessary services are not Pre-Authorization first.
reasonably available from a Participating Provider.
Covered Health Services include:
Other care, like routine care, prenatal care, preventive care,
chemotherapy, home health care services, routine diagnostic • Allergy shots
imaging, routine laboratory tests or follow-up visits, are not Your child can arrange to have allergy shots while at
covered at the In-Network Level Of Benefits when you or school. When a Participating Provider provides the
your covered dependents are out of the Service Area. allergy extracts, your child can bring them to a Non-
You or the Participating Provider must request Pre- Participating Provider near school who will give the
Authorization by calling or writing our Clinical Review shots.
Department at: • Emergency Services or Urgent Care
(860) 674-5860 or 1-800-562-6833 Emergency Services or Urgent Care are covered. If
your child needs follow up care related to that
or
Emergency or Urgent Care, call us for Pre-
ConnectiCare Authorization, even if the follow up care is given in
Clinical Review Department the emergency room.
175 Scott Swamp Road
Farmington, Connecticut 06032
For mental health or alcohol or substance abuse care, you
must call 1-888-946-4658 to request Pre-Authorization
before obtaining care.
IT IS YOUR RESPONSIBILITY to make sure written
Pre-Authorization is received before you get any
treatment by a Non-Participating Provider.
Page 17
• Behavioral Health (Mental Health, alcohol and After Hours Care
substance abuse services)
A Member is covered at the In-Network Level Of Benefits
Mental health, alcohol and substance abuse services for Urgent Care and Emergencies during and after the
are coordinated by our Behavioral Health Program normal business hours of Participating Providers. If
Delegated Program. If your child needs these services possible, please call your Primary Care Provider (PCP) in the
while at school, call our Behavioral Health Program at event you need medical care after hours. PCPs (or covering
the telephone number listed on the back of his/her PCPs) are always available.
ID card. Representatives are always available to
coordinate this care. Our Behavioral Health Program If a Member needs mental health, alcohol or substance abuse
maintains a national network of providers and will try care after hours, please call the appropriate telephone
to find a provider in your child’s area. Our Behavioral number listed on the back of your ID card. Representatives
Health Program maintains a national network of are always available to coordinate this care.
providers and will try to find a provider in your child’s
area. If necessary, it will authorize appropriate care COST-SHARES YOU ARE REQUIRED TO PAY
rendered by a Non-Participating Provider. Examples of Cost-Sharing arrangements are “Copayments”,
“Deductibles” and “Coinsurance.”
• Physical therapy
When your child’s doctor orders physical therapy Review your Benefit Summary for the applicable Cost-
treatment as a result of an accident or surgical Share amounts of this Plan, any maximums this Plan
procedure the therapy is covered. may have, and per calendar year or per Contract Year
coverage.
• Radiology services
Amount Of In-Network Level Of Benefits
Radiology services are covered when your child is at
school, including CT scans and MRI/MRA exams. Your Benefit Summary lists the amount of the In-Network
Call us so we can help you coordinate the services. Level Of Benefits that you or your Eligible Dependents will
receive when a Participating Provider renders Medically
• Prescription drugs Necessary care. In general, you are required to pay a
Prescriptions are covered at Participating Pharmacies Copayment for the In-Network Level Of Benefits before the
throughout the United States. If you have In-Network Level Of Benefits is paid, but some benefits
supplemental prescription drug coverage with us, your require you to pay a Benefit Deductible first.
child needs to present his/her ID card to the
Take a look at your Benefit Summary for Cost-Share
pharmacy, along with a prescription, and pay the
amount details.
applicable Cost-Share amount.
Amount Of Out-Of-Network Level Of Benefits
Traveling Or Residing Temporarily Out Of Your Benefit Summary lists the amount of the Out-Of-
Service Area Network Level Of Benefits that you and your Eligible
While a Member is traveling or residing temporarily out of Dependents will receive when Non-Participating Providers
the Service Area, coverage is available at the In-Network render Medically Necessary care. In general, the Out-Of-
Level Of Benefits for: Network Level Of Benefits is equal to the Coinsurance
percentage listed on your Benefit Summary multiplied by the
• Emergency Services.
Maximum Allowable Amount after the applicable Deductible
• Urgent Care. has been met.
Any continuing treatment of an illness or injury that is Any amount charged by the Non-Participating Provider
provided by Non-Participating Providers and that can be exceeding the amount of the Out-Of-Network Level Of
delayed for 24 hours or greater will not be covered at the In- Benefits is your financial responsibility.
Network Level Of Benefits unless written Pre-Authorization
is obtained first. Take a look at your Benefit Summary for Cost-Share
amount details.
Other care, such as routine care, prenatal care, preventive
care, chemotherapy, home health care services, a medical
condition that requires ongoing treatment, routine diagnostic
imaging, routine laboratory tests and follow-up visits, is not
covered at the In-Network Level Of Benefits when you or
your Eligible Dependents are out of the Service Area.
Page 18
Deductibles H ow Plan Deductibles Are Met
A Deductible is the total amount that each Member must pay The In-Network Level Of Benefits Plan Deductible amount
during the year for certain benefits under a plan before we is met by combining the total Plan Deductible amounts the
will begin paying for those benefits. Member has paid during the year for services rendered by
Participating Providers.
Your Benefit Summary describes the Deductibles that
apply to your Plan. The Out-Of-Network Level-Of-Benefits Plan Deductible
amount is determined by combining the total Plan
Plan Deductible Deductible amounts the Member has paid during the year for
In-Network Level Of Benefits Plan Deductible services rendered by Non-Participating Providers.
This Plan may require that you meet an In-Network Level In-Network Level Of Benefits Plan Deductible amounts
Of Benefits Plan Deductible for most covered Health do not accrue toward the Out-Of-Network Level Of
Services that are rendered by a Participating Provider before Benefits Plan Deductible and vice versa.
we will begin paying our portion of those benefits. After the The applicable individual (when you are the only Member
Plan Deductible is met, benefits will be paid subject to the covered under your Plan) In-Network Level Of Benefits
Member’s payment of either a Copayment amount or Plan Deductible and the Out-Of-Network Level Of Benefits
Coinsurance amount. Plan Deductible are considered to be met for a Member if
NOTE: The In-Network Level Of Benefits Plan the applicable Plan Deductibles are met by the amounts paid
Deductible DOES NOT apply to certain covered for that Member for Health Services covered by each Plan
Health Services. However, those services that are Deductible.
exempt from the In-Network Level Of Benefits Plan The applicable family (when you and one other person are
Deductible may be subject to a Copayment or covered under your Plan) In-Network Level Of Benefits
Coinsurance amount. To find out the covered Health Plan Deductible and the family (two Member) Out-Of-
Services that the In-Network Level Of Benefits Plan Network Level Of Benefits Plan Deductible are met for each
Deductible DOES NOT apply to and all the Cost-Share Member when each Member separately meets the applicable
amounts of this Plan, please refer to your Benefit individual Plan Deductible amount specified on your Benefit
Summary. Summary.
Out-Of-Network Level Of Benefits Plan Deductible An applicable family (when you and at least two other
This Plan may require that you meet an Out-Of-Network persons are covered under your Plan) In-Network Level Of
Level Of Benefits Plan Deductible for most covered Health Benefits Plan Deductible and the family (three or more
Services when they are rendered by Non-Participating Members) Out-Of-Network Level Of Benefits Plan
Providers before we will begin paying our portion of covered Deductible are met by combining the total expenses for
Health Services. After the Plan Deductible is met, benefits Health Services incurred by each family member, up to
will be paid subject to the Member’s payment of a the applicable family Plan Deductible amount as specified on
Coinsurance amount. your Benefit Summary.
Please refer to your Benefit Summary to see the amount Amounts paid by Members as their Coinsurance
of the Plan Deductibles that you are required to pay in responsibility, or because charges exceed the Maximum
this Plan. Allowable Amount, or due to a Benefit Reduction, or for
services that are not covered by this Plan do not count
towards meeting any Deductible.
The Plan Deductibles generally apply to all covered Health
Services, except those that have their own Benefit
Deductibles.
Page 19
Benefit Deductible A Member does not have to pay Emergency room
This Plan may have a specific Benefit Deductible that applies Copayments if the Member:
separately to certain benefits. For example, there may be a • Is admitted directly to the Hospital from the
Benefit Deductible for your prescription drug program (if emergency room, or
that prescription drug program has been selected as part of
this Plan). When this Plan does have a prescription drug • Was treated at an Urgent Care Center and told by
Benefit Deductible, that Benefit Deductible must be the treating provider that he/she should go
individually met by you or your Eligible Dependents each immediately to an emergency room (ER) because the
year before we will begin paying for those prescription drug ER was better equipped to handle his/her medical
benefits. Anything paid by Members for prescription drugs problem.
under this Benefit Deductible does not count towards Coinsurance
meeting any Plan Deductible amounts.
Coinsurance is the Member’s share of a percentage of the
More About Deductibles cost of covered Health Services after any applicable
Any Copayment or Coinsurance amounts paid, if any, DO Deductible is met.
NOT count towards meeting any of this Plan’s Benefit When Coinsurance applies as a result of the In-Network
Deductibles or the Plan Deductibles. Level Of Benefits, except as otherwise required by law, the
In addition, amounts you pay because charges exceed the Coinsurance amount will be calculated based on the lesser of:
Maximum Allowable Amount, due to a Benefit Reduction, • The physician’s or provider’s charges for a Health
or for services that are not covered by this Plan do not count Service at the time it is provided; or
towards meeting the Benefit Deductible or the Plan
Deductibles. • The contracted rate with the physician or provider for
the Health Service.
Plan Deductibles DO NOT need to be met for services that When Coinsurance applies as a result of the Out-Of-
have their own Benefit Deductible before we will begin Network Level Of Benefits, except as otherwise required by
paying for those benefits. However, Plan Deductibles DO law, the Coinsurance amount will be calculated based on the
need to be met for ALL other covered Health Services Maximum Allowable Amount.
before we will begin paying our share.
A charge by a physician or provider for a Health Service
Deductible and Coinsurance amounts paid for covered eligible for the Out-Of-Network Level Of Benefits that is in
Health Services under this Plan’s In-Network Level Of excess of the Maximum Allowable Amount is not considered
Benefits Plan Deductible are based on the lower of the Coinsurance and shall be your financial responsibility.
provider's billed charges for the covered Health Services or
our contracted rate. Review your Benefit Summary for Coinsurance amount
details.
Copayments
A Copayment is an In-Network Level Of Benefits Cost-
Share arrangement in which a Member pays a specific charge
directly to a provider for a covered Health Service EVERY
TIME the service is supplied.
Claims for services come to us from doctors and other
providers of health care with various billing codes on them.
Those codes determine how we will pay for covered Health
Services by identifying what service and where. The
Copayment amount a Member is required to pay depends on
that information. So, if you get a bill with a doctor’s office
visit Copayment on it, even though you may have received
the services at some place other than a doctor’s office, you
will be required to pay the doctor’s office visit Copayment.
Copayments vary by Plan. Your Benefit Summary will
describe your Copayments, if any.
Page 20
Maximums Out-Of-Network Level Of Benefits Out-Of-Pocket
Maximum
Benefit Maximums The Out-Of-Network Level Of Benefits Out-Of-Pocket
Some benefits may have a benefit maximum. When a benefit Maximum is the Member’s maximum payment liability per
does have a maximum number of visits that we will cover, year for services (including prescription drug coverage)
the benefit maximum applies to the total number of visits covered at the Out-Of-Network Level Of Benefits.
covered, whether you receive the benefit at the In-Network
Level Of Benefits or Out-Of-Network Level Of Benefits. The Out-Of-Network Level Of Benefits Out-Of-Pocket
Benefit maximums are listed on your Benefit Summary. Maximum is met for a Member if his or her individual Out-
Of-Network Level Of Benefits Out-Of-Pocket Maximum is
Out-Of-Pocket Maximums met by the eligible amounts paid by that Member for services
This Plan may have an Out-Of-Pocket Maximum. paid at the Out-Of-Network Level Of Benefits or if the
family Out-Of-Network Level Of Benefits Out-Of-Pocket
The Out-Of-Pocket Maximum amount and the Cost- Maximum is met by the total eligible amounts paid by that
Share categories that add up to meet your Out-Of- Member and all of the members in his or her family who are
Pocket Maximum are listed on your Benefit Summary. covered by the Plan.
In-Network Level Of Benefits Out-Of-Pocket When the Out-Of-Network Level Of Benefits Out-Of-
Maximum Pocket Maximum is met, the Out-Of-Network Level Of
The In-Network Level Of Benefits Out-Of-Pocket Benefits will be paid at 100% of the Maximum Allowable
Maximum is the Member’s maximum payment liability per Amount for the remainder of the year.
year for services (including prescription drug coverage)
The following amounts you pay DO NOT count towards
covered at the In-Network Level Of Benefits.
this Plan’s Out-Of-Network Level Of Benefits Out-Of-
The In-Network Level Of Benefits Out-Of-Pocket Pocket Maximum:
Maximum is met for a Member if his or her individual In-
Network Level Of Benefits Out-Of-Pocket Maximum is met • Amounts a Member pays toward any non-covered
by the eligible amounts paid by that Member for services Health Services, or
paid at the In-Network Level Of Benefits or if the family In- • Amounts a Member pays toward any In-Network
Network Level Of Benefits Out-Of-Pocket Maximum is met Level Of Benefits, or
by the total eligible amounts paid by that Member and all of • Amounts a Member pays toward any penalties or
the members in his or her family who are covered by the Benefit Reductions, or
Plan. There may be an individual maximum on this amount.
Please refer to your Benefit Summary for any maximums. • Charges by a provider in excess of the Maximum
Allowable Amount, or
When the In-Network Level Of Benefits Out-Of-Pocket
Maximum is met, the In-Network Level Of Benefits will be • Difference in price a Member pays in the Generic
paid at 100% of the contracted rate with physicians or Substitution Program.
providers for remainder of the year. Your Benefit Summary describes any Out-Of-Pocket
The following amounts you pay DO NOT count towards Maximum.
this Plan’s In-Network Level Of Benefits Out-Of-Pocket
Maximum:
• Amounts a Member pays toward any non-covered
Health Services, or
• Amounts a Member pays toward any Out-Of-
Network Level Of Benefits, or
• Amounts a Member pays toward any penalties or
Benefit Reductions, or
• Charges by a provider in excess of the Maximum
Allowable Amount, or
• Difference in price a Member pays in the Generic
Substitution Program.
Your Benefit Summary describes any Out-Of-Pocket
Maximum.
Page 21
MEDICAL NECESSITY AND APPROPRIATE QUALITY ASSURANCE
SETTING FOR CARE The goal of the Quality Improvement (QI) Program is to
establish processes that lead to continuous improvement of
“Medically Necessary” means those Health Services that a
the care and services provided to our Members. The QI
health care practitioner, exercising prudent clinical judgment,
Program helps us to better serve Members, employers,
would provide to a patient for the purpose of preventing,
Participating Providers. Through the QI Program we:
evaluating, diagnosing or treating an illness, injury, disease or
its symptoms, and that are: • Systematically monitor, evaluate and suggest
1. In accordance with “generally accepted standards of improvements for both the process of care and the
medical practice;” outcome of care delivered to Members.
2. Clinically appropriate, in terms of type, frequency, extent, • Identify and implement opportunities for
site and duration and considered effective for the improvement in the quality of care and services
patient's illness, injury or disease; and delivered to Members, both administrative and
clinical, including behavioral health.
3. Not primarily for the convenience of the patient,
physician or other health care provider and not more • Evaluate and improve Members’ access to and
costly than an alternative service or sequence of services satisfaction with clinical and administrative services.
at least as likely to produce equivalent therapeutic or • Facilitate Members’ access to appropriate medical
diagnostic results as to the diagnosis or treatment of that care.
patient's illness, injury or disease.
• Encourage Members to become more
"Generally accepted standards of medical practice" means knowledgeable, active participants in their own
standards that are based on credible scientific evidence medical and preventative care by implementing
published in peer-reviewed medical literature generally initiatives that focus on member education and
recognized by the relevant medical community or otherwise health management wellness programs.
consistent with the standards set forth in policy issues
involving clinical judgment. • Carry out systematic data collection related to plan
and practitioner performance and communicate, in
“Medically Necessary” health care services are those Health the aggregate, these data and their interpretation to
Services that are required diagnostic or therapeutic internal and peer review committees for analysis and
treatments for an illness or injury. action.
Health care treatments, medications and supplies that are not • Monitor whether the care and service provided
Medically Necessary are not covered under this Plan. We meets or exceeds established local, state, and
determine if a treatment, medication or supply is Medically national managed care standards.
Necessary. These determinations are made through various
• Develop innovative approaches to facilitating the
Utilization Management processes, including pre service
delivery of care to diverse populations.
review, concurrent review, post service review, discharge
planning and Case Management. The scope of activities within the QI Program focuses on
facilitating: quality of care and services, continuity and
A health care practitioner determines medical care, but coordination of care, chronic care management,
coverage for that care under this Plan is subject to Medical credentialing, behavioral health, Member safety, utilization
Necessity as determined by us. We use input from management, Member and physician satisfaction,
physicians, including specialists, to approve, and in some accessibility, availability, delegation, Member complaints and
cases develop, our Medical Necessity protocols. Appeals, cultural diversity, wellness and prevention,
Case Managers help to arrange and coordinate Medically pharmacy management, and Member decision support tools.
Necessary care. Alternative individual plans may include
coverage of otherwise non-covered services or supplies.
UTILIZATION MANAGEMENT
Utilization Management decisions are made using medical
protocols developed from national standards with local
physician input. We do not reward practitioners or other
individuals conducting utilization review for issuing denials
of coverage for health care treatments, medications or
supplies. We do not provide financial incentives to
encourage Utilization Management decision-makers to deny
coverage for Medically Necessary care.
Page 22
NEW TREATMENTS EXPERIMENTAL OR INVESTIGATIONAL
New Treatments are new supplies, services, devices, A service, supply, device, procedure or medication
procedures or medications, or new uses of existing supplies, (collectively called "Treatment") will be considered
services, devices, procedures or medications, for which we Experimental Or Investigational if any of the following
have not yet made a coverage policy. conditions are present:
When we receive a request for coverage for a New 1. The prescribed Treatment is available only through
Treatment, we review the New Treatment to determine participation in a program designated as a clinical trial,
whether it should be covered under this Plan. whether a federal Food and Drug Administration (FDA)
Phase I or Phase II clinical trial, or an FDA Phase III
Generally, New Treatments, other than drugs with FDA
experimental research clinical trial or a corresponding
approval for the use for which they are prescribed, are not
covered. However, during our review phase of a New trial sponsored by the National Cancer Institute, or
Treatment, we may, in some limited circumstances, cover a another type of clinical trial; or
New Treatment for Members in the same or similar 2. A written informed consent form or protocols for the
circumstances before our determination is made. Once we Treatment disclosing the experimental or investigational
complete our review, if we determine the New Treatment nature of the Treatment being studied has been reviewed
should be covered, those New Treatments rendered AFTER and/or has been approved or is required by the treating
our determination will be covered. There will be no facility's Institutional Review Board, or other body
retroactive coverage of a New Treatment. serving a similar function or if federal law requires such
review and approval; or
If we determine the New Treatment should not be covered
by this Plan, then the New Treatment will continue to be 3. The prescribed Treatment is subject to FDA approval
excluded. and has not received FDA approval for any diagnosis or
condition.
In the case where a New Treatment is a prescription drug
with FDA approval for the use for which it is being If a Treatment has multiple features and one or more of its
prescribed, the medication will be covered at the highest tier essential features are Experimental Or Investigational based
Copayment level until our Pharmacy and Therapeutics on the above criteria, then the Treatment as a whole will be
(P&T) Committee has had an opportunity to review it, unless considered to be Experimental Or Investigational and not
it is in a class of medication that is specifically excluded as covered.
described in the "Exclusions And Limitations" section. We will monitor the status of an Experimental Or
A New Treatment may also require Pre-Authorization. Investigational Treatment and may decide that a Treatment
When the P&T Committee does its review, it will decide if which at one time was considered Experimental Or
the medication will remain at the highest tier cost share level Investigational may later be a covered Health Service under
or be switched to a lower tier cost share level, and also this Plan. No Treatment that is or has been determined by
whether the medication will have Pre-Authorization us to be Experimental Or Investigational, will be considered
requirements or dosage limits placed on it. When you as a covered Health Service under this Plan until such time as
receive a medication that is a New Treatment, the conditions the Treatment is deemed by us to be no longer Experimental
under which you can receive the medication might change Or Investigational and we have determined that it is
after the P&T Committee completes its review. Medically Necessary in treating or diagnosing an illness or
injury.
To obtain information about whether a procedure,
medication, service, device or supply is a New Treatment, or Coverage for a Treatment will not be denied as Experimental
if a New Treatment requires Pre-Authorization, or to obtain Or Investigational if a Treatment has successfully completed
information about whether we have made our determination a Phase III clinical trial of the FDA for the condition being
with respect to a New Treatment, you should contact our treated or for the diagnosis for which it is prescribed.
Member Services Department.
Page 23
Certain Investigational Items Outside Of INSUFFICIENT EVIDENCE OF THERAPEUTIC
Clinical Trials VALUE
For the purposes of this subsection, an “Investigational Any service, supply, device, procedure or medication
Item” means a drug, biological product or device which has (collectively called “Treatment”) for which there is
successfully completed a Phase One clinical trial of the FDA, Insufficient Evidence Of Therapeutic Value for the use for
but which has not yet been approved for general use by the which it is being prescribed is not covered. There is
federal drug administration (FDA) and which remains under insufficient evidence of therapeutic value when we determine
investigation in clinical trial approved by the FDA. A that either:
“Terminal Illness” means a medical condition which the 1. There is not enough evidence to prove that the
patient’s treating physician anticipates with reasonable Treatment directly results in the restoration of health or
medical judgment will result in a patient’s death or a state of function for the use for which it is being prescribed,
permanent unconsciousness from which recovery is unlikely whether or not alternative Treatments are available; or
within a period of one year.
2. There is not enough evidence to prove that the
Connecticut law allows patients with a Terminal Illness who
Treatment results in outcomes superior to those achieved
meet certain qualifications to be treated with Investigational
with reasonable alternative Treatments which are less
Items outside of clinical trials. The cost of such an
intensive or invasive, or which cost less and are at least
Investigational Item is excluded under this Plan. Any costs
equally effective for the use for which it is being
associated with or incurred as a result of such treatment with
prescribed.
an Investigational Item are excluded under this Plan,
beginning on the date treatment with the Investigational There may be Insufficient Evidence Of Therapeutic Value
Item begins and ending six months after the date the for a Treatment even when it has been approved by a
treatment ends. Any costs associated with or incurred as a regulatory body or recommended by a health care
result of treatment with an Investigational Item which has practitioner.
been provided outside of the requirements of Connecticut We will monitor the status of a Treatment for which there is
law are excluded without limitation. Insufficient Evidence Of Therapeutic Value and may decide
You are required to provide us with a copy of the executed that a Treatment for which at one time there was Insufficient
written informed consent document if you begin treatment Evidence Of Therapeutic Value may later be a covered
with an Investigational Item. You are responsible for Health Service under this Plan. Coverage will not become
reimbursing us for any costs paid by us for Investigational effective until we have made a determination that there is
Items, or for costs associated with or incurred as a result of sufficient evidence of therapeutic value for the Treatment
treatment with an Investigational Item that are excluded as and we have decided to make the Treatment a covered
described above. Health Service. All Treatment with sufficient evidence of
therapeutic value must also be Medically Necessary to treat
Please refer to the other provisions in this “Experimental Or or diagnose illness or injury in order to be covered.
Investigational” subsection for more information about
coverage of Experimental Or Investigational treatments. In DELEGATED PROGRAMS
addition, please refer to the “Benefits” section for more
We may use outside companies to manage and administer
information about coverage of clinical trials.
certain categories of benefits or services provided under this
Plan. These outside companies make decisions and act on
our behalf.
Delegated Programs may be added or removed from this
Plan at any time.
Page 24
BENEFITS Adults
Adults have coverage for the following routine exams and
Benefits for Medically Necessary Health Services provided
preventive care.
under this Plan are subject to all the rules of this document.
If you use Participating Providers for your care, you will be Preventive Care Medical Services
eligible for the highest level of benefits under this Plan. This Preventive care medical services (routine exams and
is called the “In-Network Level Of Benefits.” preventive care) for adults age 19 and over are covered.
If you use Non-Participating Providers to order, arrange or Gynecological Preventive Exam Office Services
provide you your care, then you will be eligible for a lower Gynecological preventive exam office services are covered.
level of benefits, called the “Out-Of-Network Level Of
Benefits.” The Member’s doctor decides the number of times she
should get periodic health evaluations and checkups.
Please review your Benefit Summary for the amounts you
have to pay (Copayment, Deductible, Coinsurance amounts), Routine Eye Care
and the benefit maximums of this Plan. Routine eye care for adults over age 20 is covered up to the
PREVENTIVE AND WELLNESS CARE maximum benefit, as shown on your Benefit Summary.
Some Participating Provider preventive and wellness Preventive Exams And Preventive Care Limitations
services, as defined by the United States Preventive Unless specified in this “Routine Medical Exams And
Service Task Force, including immunizations Preventive Care” subsection, not covered under this
recommended by the Advisory Committee on subsection are charges for:
Immunizations Practices at the Centers for Disease
Control (CDC), and preventive care and screenings for • Services which are covered to any extent under any
infants, children, adolescents, and women supported by other part of this Policy,
the Health Resources and Services Administration • Services which are for diagnosis or treatment of a
(HRSA) are exempt from all Member Cost-Shares suspected or identified illness or injury,
(Deductible, Copayment and Coinsurance) under the
federal Patient Protection and Affordable Care Act • Exams given during your inpatient stay for medical
(PPACA). These services are identified by the specific care,
coding your provider submits to ConnectiCare. The • Services not given by a physician or under his or her
service coding must match ConnectiCare’s coding list direction, and
to be exempt from all Cost-Sharing under PPACA. You • Psychiatric, psychological, personality or emotional
should visit our website at www.connecticare.com to testing or exams.
view a list of the preventive and wellness services that
are exempt from Member Cost-Shares or call our Pediatric Dental Care (Under Age 20)
Member Services Department at the telephone number
IMPORTANT: If you opt to receive Dental Services
listed in the “Important Telephone Numbers And
that are not covered benefits under this Plan, a
Addresses” section for assistance.
Participating Provider, including a Dentist may charge
PREVENTIVE SERVICES you his or her usual and customary rate for such
The following preventive services are covered in a doctor’s services or procedures. Prior to providing you with
office. Dental Services that are not covered benefits, the dental
provider should provide you with a treatment plan that
Routine Medical Exams And Preventive Care includes each anticipated service or procedure to be
provided and the estimated cost of each such service or
Infants/Children procedure.
Infants/children have coverage for the following routine
exams and preventive care. Whenever covered Dental Services are expected to
exceed $250, or whenever services such as orthodontics,
Preventive Care Medical Services
dentures, crowns, periodontics or bridgework are to be
Preventive care medical services (routine exams and done, you may ask your Dentist to submit a request for
preventive care) for infants/children under age 19 are predetermination of covered benefits. This step protects
covered. you and your Dentist, since it advises you both in
Routine Eye Care advance as to what portion of your dental treatment
costs may be paid by us, as long as you are still eligible
Routine eye care, including refraction (a test to determine
for benefits. This is a very common procedure and your
whether you are near-sighted or far-sighted) for
Dentist will be pleased to complete the reporting form.
infants/children under age 20 is covered up to the
You need not do anything more at that time.
maximum benefit, as shown on your Benefit Summary.
Page 25
Medically Necessary pediatric dental care is covered as General Services
follows: Benefits for other adjunctive general services as described in
Diagnostic Services the American Dental Association (ADA) Code on Dental
Oral examinations and diagnostic casts. Procedures and Nomenclature (CDT Code)™ , which are
not included in the specific categories listed above, include
X-Rays (where applicable) general anesthesia, IV sedation, and
Full mouth x-ray series, periapical x-rays, bitewing x-rays, behavior management.
panoramic x-rays.
Pediatric Dental Care Exclusions And Limitations
Preventive
There is no coverage or coverage is limited for Dental
Prophylaxis, fluoride applications, and space maintainers.
Services, including, but not limited to the following:
Restorative
Treatment of tooth decay include the use of amalgam and/or • Any service, procedure, or treatment modality not
composite restorations (fillings). specifically listed in this “Pediatric Dental Care
(Under Age 20)” subsection,
Restorative-Crowns
The use of stainless steel, gold, semiprecious, or non- • For adults (Members age 20 and over),
precious metals to restore a tooth or teeth which cannot be • Dental treatments, medications and supplies that are
restored with amalgam or composite restorations. not Medically Necessary,
Endodontics • Experimental Or Investigational procedures,
Treatment of the diseases of the nerve of the tooth include • Procedures to alter vertical dimension (bite height
pulp capping, pulpotomy, root canal, apexification and based on the resting jaw position) including but not
apicoectomy. limited to, occlusal (bite) guards and periodontal
Periodontics splinting appliances (appliances used to splint or
Treatment of the supporting tissues of the teeth, gums, and adhere multiple teeth together), and restorations
underlying bone, with either surgical or non-surgical (filings, crowns, bridges, etc.),
procedures (where applicable) include gingivectomy or • Space maintainers for dependent children age ten and
gingivoplasty. over,
Prosthetics-Removable • Services or supplies rendered or furnished in
Replacement of missing teeth by the use of a removable connection with any duplicate prosthesis or any other
appliance include full and cast or acrylic partial dentures. duplicate appliance,
Prosthetics Adjustment • Restorations which are not of any dental health
Repair or modification of existing removable and/or fixed benefit, but primarily Cosmetic Treatment in nature,
appliances so that they can continue to be serviceable include including, but not limited to laminate veneers,
adjustments, repairs, rebasing and relining.
• Payment of the applicable Cost-Share of this Plan’s
Prosthetics Fixed Maximum Allowable Amount for the alternate
The use of gold, semiprecious, or precious metal to replace a service, if any, will be made toward such treatment
missing tooth or teeth, which cannot otherwise be replaced and the balance of the cost remains the responsibility
with a removable appliance include fixed partial denture of the Member,
pontics and crowns.
• Personalized, elaborate, or precision attachment
Dental Implants dentures or bridges, or specialized techniques,
A device specifically designed to be placed surgically within including the use of fixed bridgework, where a
or on the mandibular or maxillary bone as a means of conventional clasp designed removable partial denture
providing for dental replacement are NOT covered. would restore the arch,
Extractions • Payment of the applicable Cost-Share of this Plan’s
The extraction, either simple or surgical, of either a single Maximum Allowable Amount for the alternate
tooth or multiple teeth, the shaping of bone ridges, the service, if any, will be made toward such treatment
removal of a tooth end abscess, etc. are included. and the balance of the cost remains the responsibility
Bony Impactions of the Member,
The surgical removal of teeth partially or fully covered by
bone are included.
Orthodontics
The straightening of teeth for dental health reasons are
included.
Page 26
• General anesthesia, except for the following reasons: • Expenses incurred for the replacement of a denture,
♦ Removal of one or more impacted teeth; crown, or bridge for which benefits were previously
paid, if such replacement occurs within five years
♦ Removal of four or more erupted teeth; from the date of the previous benefit,
♦ Treatment of a physically or mentally impaired • Training in plaque control or oral hygiene, or for
person; dietary instruction,
♦ Treatment of a child under age 11; and • Completion of reporting forms,
♦ Treatment of a Member who has a medical • Charges for missed appointments,
problem, when the attending physician requests in
writing that the treating Dentist administer general • Charges for services and supplies which are not
anesthesia. This request must accompany the necessary for treatment of the injury or disease, or are
dental claim form. not recommended and approved by the attending
Dentist, or charges which are not reasonable,
• Duplicate charges,
• Scaling and root planing which is not followed, where
• Services incurred prior to the effective date of indicated, by definitive pocket elimination procedures.
coverage, In the absence of continuing periodontal therapy,
• Services incurred after cancellation of coverage, or scaling and root planning will be considered a
losses of eligibility, prophylaxis and subject to the limitations of that
procedure,
• Services incurred in excess of any Contract Year
maximum, • Periodontal surgery procedures more than once per
quadrant in any period of 36 consecutive months,
• Services or supplies that are not Medically Necessary
according to accepted standards of dental practice, • More than one periodontal scaling and root planning
per quadrant in any consecutive 36 month period,
• Services that are incomplete,
• More than two periodontal maintenance procedures
• Orthodontic services for persons age 20 and over, in any consecutive 12-month period, as well as
when orthodontics is a covered Dental Service, periodontal therapy, periodontal maintenance
• Sealants on teeth other than the first and second procedures in the absence of benefited
permanent molars, or applications applied more comprehensive,
frequently than every thirty-six months or a service • Services for any condition covered by workers’
provided outside of ages five through fourteen, compensation law or by any other similar legislation,
• Services such as trauma which are customarily • Services to correct or in conjunction with treatment
provided under medical-surgical coverage, of congenital malformations (e.g., congenitally
• More than two oral examinations of any type in any missing teeth, supernumerary teeth, enamel and dental
consecutive 12-month period, dysplasia), developmental malformation of teeth, or
• More than two prophylaxes in any consecutive 12- the restoration of teeth missing prior to the effective
month period, date of coverage, and
• More than one full mouth x-ray series in any period • Claims submitted more than 11 months (335 days)
of 36 consecutive months, following the date of service.
• Bitewing x-rays or vertical bitewing x-rays in excess of
eight films in any consecutive 12-month period,
• Adjustments or repairs to dentures performed within
six months of the installation of the denture,
• Services or supplies in connection with periodontal
splinting (adhering multiple teeth together),
• Implants and implantology services, including implant
bodies, abutments, attachments and implant
supported prosthesis (such as crowns, dentures,
pontics, or bridgework),
• Expenses incurred for the replacement of an existing
denture which is or can be made satisfactory,
• Additional expenses incurred for a temporary denture,
Page 27
Routine Cancer Screenings This Plan will not require the Member to pay:
The following routine cancer screenings are covered as • A Deductible amount for a procedure that his/her
noted in the following provisions. doctor initially performs as a screening colonoscopy
or a screening sigmoidoscopy in accordance with the
Blood Lead Screening Exams And Risk Assessments American Cancer Society recommendations, or
If the Member’s Primary Care Provider decides that blood
• Any Cost-Share amount for repeat colonoscopies
lead screenings and risk assessments are needed, they are
ordered by a doctor in a benefit year, unless the
covered as follows:
Member is enrolled in one of our HSA-compatible
Lead Screening Exams high deductible health plans (HDHPs).
• At least annually for a child from 9-35 months of age, Mammogram Screenings
and Mammogram screenings are covered.
• For a child 3-6 years of age who has not been The following suggests how often mammogram screenings
previously screened or is at risk. should be obtained, but the Member’s doctor decides the
Risk Assessments number of times a Member should get mammogram
screenings.
• For lead poisoning at least annually for a child 3-6
years of age, and Mammogram Screenings
• At any time in accordance with state guidelines for a Ages 35 to 39: One baseline screening
child age 36 months or younger. Age 40 and over: One screening mammogram per
year
Cervical Cancer Screening (Pap Tests) Breast tomosynthesis screening (a three dimensional method)
Cervical cancer screenings (pap tests) for female Members is another mammogram option covered under this Plan.
are covered. These services are covered at the applicable non-
The Member’s doctor decides the number of times she advanced radiology Cost-Share as shown on your
should get cervical cancer screenings. Benefit Summary.
Colorectal Cancer Screenings There is no coverage for diagnostic breast tomosynthesis

services.
Colorectal cancer screenings, using fecal occult blood testing,
sigmoidoscopy, colonoscopy, or radiological imaging, are In addition to the mammogram screenings noted above,
covered in accordance with the recommendations comprehensive ultrasound screening of an entire breast or
established by the American Cancer Society, based on the breasts is also covered at the applicable Cost-Share as
ages, family histories and frequencies provided in the shown on your Benefit Summary.
recommendations. Ultrasound screening of an entire breast or breasts is
• If the screening is coded as preventive, a Member can covered, if:
get one screening per year. • A mammogram demonstrates heterogeneous or dense
• If the screening is not preventive, the Member’s breast tissue based on the Breast Imaging Reporting
doctor decides the number of times he/she should and Data System established by the American College
get colorectal cancer screenings. of Radiology; or
You may have to pay a Cost-Share for these screenings. The • A woman is believed to be at increased risk for breast
amount depends on where the procedure is received and cancer due to family history or prior personal history
your Plan. For example, if you have a procedure done at a of breast cancer, positive genetic testing or other
doctor’s office, you may be required to pay an office services indications as determined by her physician or
Copayment, but if you get the service on an outpatient basis, advanced practice registered nurse.
either in a Hospital or in an ambulatory surgery facility, you Magnetic resonance imaging (MRI) of an entire breast or
may be required to pay an ambulatory services Cost-Share breasts in accordance with guidelines established by the
amount. American Cancer Society is covered at the applicable
advanced radiology Cost-Share as shown on your
Benefit Summary.
Some types of breast cancer screenings (e.g., when a Member
has or is thought to have a clinical genetic disorder) require
Pre-Authorization.
Page 28
Prostate Screening Newborn Care
Laboratory and diagnostic tests to screen for prostate cancer Newborn children are covered for the first 61 days
are covered for a Member who: following birth.
• Is at least 50 years old, or Please refer to the “Adding New Children” subsection of the
“Eligibility And Enrollment” section for more information
• Is any age and is also symptomatic, or
and rules regarding coverage for newborn children.
• Is any age and has a biological father or brother who
has been diagnosed with prostate cancer. OUTPATIENT SERVICES
In addition, treatment for prostate cancer will also be This Plan covers Medically Necessary services provided in
covered in accordance with national guidelines established the doctor’s office, including consultations. It also covers
by the National Comprehensive Cancer Network, the Medically Necessary services in the Member’s home to treat
American Cancer Society or the American Society of Clinical an illness or injury.
Oncology.
Allergy Testing
Routine Cancer Screening Limitations Allergy testing with allergenic extract (or RAST allergen
Unless specified in this “Routine Cancer Screenings” specific testing) is typically covered after the applicable
subsection, there is no coverage under this subsection for Cost-Share up to the maximum benefit as shown on
other services that are covered to any extent under any other your Benefit Summary. In addition, allergy testing for
part of this Policy. medicine, biological or venom sensitivity is typically covered
after the applicable Cost-Share up to the maximum
Other Preventive Services benefit as shown on your Benefit Summary.
Hearing Screenings Benefit maximums apply to the total allergy testing benefits,
Hearing screenings are covered: whether at the In-Network Level Of Benefits or at the Out-
Of-Network Level Of Benefits.
• As a part of a physical examination if a Member is
under age 21, and Chiropractic Services
• If Medically Necessary to evaluate the sudden onset Medically Necessary short-term chiropractic services include
of severe symptoms of an injury or illness. No office visits and manipulation. These services are covered
coverage is available if the Member is already after the applicable Cost-Share up to the maximum
diagnosed with a permanent hearing loss. benefit as shown on your Benefit Summary if they are
Immunizations expected to return function to the same level the Member
Immunizations (vaccine and injection of vaccine) are had before he/she became injured or ill.
covered. There is no coverage for chiropractic manipulation of the
The following immunizations are NOT covered: cervical spine that is long term or maintenance in nature.
• Immunizations a Member gets only because someone Gynecological Office Services

else says he/she needs them (for example, to get a job Gynecological services in a doctor’s office are covered.
or to go to camp),
• Immunizations received for travel,
Laboratory Services
Outpatient laboratory services, including services a Member
• Immunizations and vaccinations for cholera, plague receives in a Hospital or laboratory facility, are covered after
or yellow fever. the applicable Cost-Share amount as shown on your
• Routine immunizations received at an Urgent Care Benefit Summary.
Center, and Some laboratory services require Pre-Authorization to be
• Vaccinations an employer is legally required to covered.
provide because of an employment risk.
Page 29
Maternity Care Office Services Radiological Services
Maternity services (pre-natal and post-partum) in a doctor’s Medically Necessary outpatient diagnostic x-rays and
office are covered. There may be a Cost-Share that the therapeutic procedures are covered. We may use an outside
Member will have to pay for care related to pregnancy for company to manage and administer this program.
each visit, even after the initial pre-natal office visit. The
The services performed in a Hospital or radiological facility
Cost-Share amount depends on where the services are
are covered after the applicable Cost-Share amount as
received. Preventive maternity care office services are
shown on your Benefit Summary. The Cost-Share amount
exempt from all Member Cost-Shares under the federal depends on where the Member receives the services.
Patient Protection and Affordable Care Act (PPACA).
Some radiology services require Pre-Authorization to be
Outpatient Habilitative Therapy And covered. Covered radiology services are as follow:
Rehabilitative Therapy, Including Physical, • Computerized Axial Tomography (CAT),
Occupational and Speech Therapy
• Magnetic Resonance Imaging (MRI),
Medically Necessary short term outpatient habilitative
therapy and rehabilitative therapy (including those services a • Positron Emission Tomography (PET),
Member receives at a day program facility or in an office) • Nuclear cardiology,
and devices, as described in the “Disposable Medical
• Bone densitometry scans,
Supplies And Durable Medical Equipment (DME), Including
Prosthetics” subsection are covered after the applicable • Ultrasound, and
Cost-Share amount as shown on your Benefit Summary. • X-rays (e.g., chest x-rays)
Physical, occupational, and speech therapy coverage is
covered as follows: Specialist Office Services
When a Member has an injury or illness that requires a
• The services must be ordered by a physician, and special doctor to treat it and the care can be obtained in a
• The services are limited to short term physical, Specialty Physician’s office, the services are covered subject
occupational and speech therapy to the Specialist Office Services Cost-Share amount.
Services are no longer covered once therapeutic goals have
EMERGENT/URGENT CARE
been met or when a home exercise program is appropriate to
achieve further gains. Ambulance/Medical Transport Services
Physical therapy for the treatment of temporomandibular Emergency Services
joint (TMJ) dysfunction is covered as follows: Emergency land or air ambulance/medical transport services
• Post-operative physical therapy for surgery is covered are covered after the Cost-Share amount as shown on
when the TMJ surgery is covered under this Plan, your Benefit Summary only for Medically Necessary
Emergency transportation if the Member requires
• Pre-Authorization is required as part of the surgical Emergency Services and the Member’s medical condition
procedure, and prevents the Member from getting to a health care facility
• Physical therapy must be provided during the 90-day safely by any other means, as determined by us.
period beginning on the date of the covered TMJ
surgery. Non-Emergency Services
Non-Emergency land or air ambulance/medical transport
There is no coverage for rehabilitative physical,
services for non-routine care visits will be covered only
occupational and speech therapy that is long term or
when Medically Necessary and with Pre-Authorization if the
maintenance in nature.
Member’s medical condition prevents safe transport to a
Primary Care Provider Office Services health care facility by any other means.
When a Member has an injury or illness that does not require Ambulance/medical transportation services will also be
a special doctor to treat it and the care can be obtained in a covered, if the Member is in-patient at an acute care facility
Primary Care Provider’s office, the services are covered and needs air transportation to another acute care facility
subject to the Primary Care Provider Office Services Cost- because Medically Necessary services to help the Member are
Share amount. not available in the facility where the Member is confined.
There is no coverage for ambulance services that are non-
Emergency medical transport services or chair car to and
from a provider’s office for routine care or if the transport
services are for a Member’s convenience.
Page 30
Emergency Services Walk-In Care
Emergency Services provided both within and outside of the Walk-in care is covered after the Cost-Share amount as
Service Area are covered at the In-Network Level Of shown on your Benefit Summary. The following rules
Benefits for Cost-Sharing, whether a Member receives apply to the use of a Walk-In Care Clinic:
Emergency Services from a Participating Provider or a Non-
Participating Provider. You may be responsible to pay a bill • Use a Walk-In Care Clinic only when your doctor is
submitted to you by Non-Participating Providers for their unable to provide or arrange for the treatment of
charges over and above the amount paid by us. common ailments like:
♦ Colds, flu symptoms, sore throat, cough or upper
In the event of an Emergency, the Member should get
respiratory symptoms,
medical assistance as soon as possible. In an Emergency 911
should be called and/or the Member should get care from: ♦ Ear or sinus pain,
• The closest emergency room, or ♦ Minor cuts, bruises, or scrapes
• A Participating Hospital emergency room. ♦ Rash, hives, stings and bites,
If possible, you or your representative should contact ♦ Sprains
your Primary Care Provider (PCP) or, for mental NOTE: The use of a Walk-In Care Clinic is usually less
health care or alcohol and substance abuse expensive than the use of an Urgent Care Center.
Emergencies, your practitioner or our Behavioral There is no coverage for routine physical exams,
Health Program prior to obtaining care, so your PCP, immunizations or follow-up care at a Walk-In Care Clinic.
your practitioner or our Behavioral Health Program
can be involved in the management of your health AMBULATORY SERVICES (OUTPATIENT)
care.
Medically Necessary ambulatory services (outpatient) are
Determination of whether a condition is an Emergency rests covered. Ambulatory services include procedures performed
with us. by a doctor on an outpatient basis, whether in a Hospital, at
a Hospital Outpatient Surgical Facility, or at an Ambulatory
Urgent Care/Walk-In Care Surgery Center. To locate a Participating Provider that is a
Urgent Care Hospital Outpatient Surgical Facility or an Ambulatory
Urgent Care is covered after the Cost-Share amount as Surgery Center, you can refer to our Provider Directory, visit
shown on your Benefit Summary. The following rules us at our web site at www.connecticare.com, or call us.
apply to the use of an Urgent Care Center: There may be a Cost-Share that you will have to pay for
Medically Necessary ambulatory surgery or certain
• Use an Urgent Care Center only when your doctor is
radiological diagnostic procedures.
unable to provide or arrange for the treatment of an
illness or injury, and Some of these services require Pre-Authorization from us.
• If you want the follow up care to be covered at the
INPATIENT SERVICES
highest level of benefits that this Plan offers, then you
must use a Participating Provider. Hospital Services
Continuing care and follow-up care in an Urgent Care Pre-Certification Rules For Non-Emergencies
Center are not covered, even if the center is a
All non-Emergency Inpatient admissions must be Pre-
Participating Providers. However, the removal of
Certified at least five business days before the Member is
stitches is covered, if the same Urgent Care Center
admitted.
used to obtain the stitches is used to take them out.
Special Pre-Authorization rules apply to transplant services.
There is no coverage for routine physical exams or
Pre-Authorization must be obtained ten business days before
immunizations at an Urgent Care Center.
any evaluative transplant services are performed.
Page 31
General Hospitalizations Mastectomy Services
Medically Necessary inpatient Hospital services generally Health Services for a mastectomy or lymph node dissection
performed and usually provided by acute care general are covered.
Hospitals with Pre-Certification from us are covered.
• If the Member is admitted to a Hospital, we will cover
Examples of covered inpatient Hospital Health Services are: a minimum of a 48-hour length of stay following the
• Administration of whole blood, blood plasma and mastectomy or lymph node dissection. We will cover
derivatives, a longer stay if the Member’s doctor recommends it.
• Anesthesia and oxygen services, • If medically appropriate, and if the Member and
his/her attending doctor approve, the Member may
• Autologous blood transfusions (self-donated blood) choose a shorter Hospital length of stay or have the
• Doctor services, services performed in an outpatient facility.
• Drugs and biologicals, Maternity Services
• Intensive care unit and related services, Inpatient Services
• Laboratory, x-ray and other diagnostic tests, Any Member who is admitted to a Hospital to have her baby
• Nursing care, will be covered for a minimum of a 48-hour length of stay
for a vaginal delivery and a minimum of a 96-hour length of
• Operating room and related facilities, stay for a caesarean delivery.
• Room and board in a semi-private room, and The time periods begin at the time the baby is delivered.
• Therapy: cardiac rehabilitation, inhalation,
occupational, physical, pulmonary, radiation and Post-Discharge Benefits
speech. If the Member and her newborn baby stay in the Hospital
for the 48 or 96-hour period, the following post-discharge
Dental Anesthesia home health services will be covered:
Medically Necessary anesthesia, nursing and related Hospital
• Vaginal Delivery (48-Hour Length of Stay)
services for the treatment of dental conditions are covered
when: One skilled nursing visit by a maternal child health
nurse from a Home Health Agency (requires Pre-
• The services, supplies or medicines are Medically Authorization from us).
Necessary as determined by the Member’s dentist or
oral surgeon and his/her Primary Care Provider Medically Necessary comprehensive lactation visits at
(PCP), and home after the delivery.
• A licensed dentist and a doctor specializing in primary • Caesarean Delivery (96-Hour Length of Stay)
care decide the Member has a complicated dental Medically Necessary comprehensive lactation visits at
condition that requires treatment be done in a home after the delivery.
Hospital, or
Optional Early Discharge Programs
A licensed doctor specializing in primary care decides If medically appropriate, and if the Member and her
the Member has a developmental disability that puts attending doctor both approve, a Member may choose a
the Member at serious risk. shorter Hospital length of stay. In these situations, the
Medically Necessary anesthesia for the treatment of dental following home health services will be covered:
conditions may also be covered in an outpatient setting as
long as both of the above conditions are met. • Vaginal Delivery with Less than 48-Hour Length of
Stay; or Caesarean Delivery with Less than 96-Hour
Outpatient facility and anesthesia charges are covered if the Length of Stay
Member needs to have dental services performed in an
Two skilled nursing visits by a maternal child health
outpatient facility because the Member has a serious medical nurse from a Home Health Agency within two weeks
condition that requires close monitoring or treatment during
of the delivery (requires Pre-Authorization from us).
the procedure. In this situation, we do not pay for what the
provider charges during the procedure (usually called Medically Necessary comprehensive lactation visits at
“professional fees”). home after the delivery.
Page 32
Testing for Bone Marrow Transplant Pre-Authorization Rules
Expenses arising from human leukocyte antigen testing (also Except for cornea transplants, all requests for transplants
known as histocompatibility locus antigen testing) for A, B and related services require Pre-Authorization at the time of
or DR antigens for use in bone marrow transplantation are diagnosis. Pre-Authorization must be obtained at least
covered after the applicable Cost-Share when the testing ten business days before any evaluative services have
is performed in a facility both accredited by the American been received.
Society for Histocompatibility and Immunogenetics and If Pre-Authorization has not been obtained, payment for the
certified under the Clinical Laboratory Improvement Act of transplant and related services, as well as for medical
1967. diagnosis and evaluation, will be reduced or denied as
The Cost-Share for the testing depends on who ordered the described in this document.
procedures and where the procedures are provided, and shall A Member may use any provider for transplants. However,
not be more than 20% of the cost of such testing per year, to obtain the In-Network Level Of Benefits, you must use
unless the Member is enrolled in one of our HSA-compatible Participating Providers. By using Participating Providers you
high deductible health plans (HDHPs). reduce your out-of-pocket expenses.
Coverage for the testing is limited as follows: Donor Benefits
• To a Member who, at the time of the testing, Medically Necessary expenses of organ donation, including
completed and signed an informed consent form that Medically Necessary services and tests to determine if the
also authorizes the results of the test to be used for organ or the bone marrow/stem cell type is a suitable match,
participation in the National Marrow Donor Program, are covered after the applicable Cost-Share amount. The
and Cost-Share amount depends on where the procedures are
• One testing per Member per lifetime. received.
Donor coverage is only available if the transplant recipient is
Solid Organ Transplants And Bone Marrow our Member and Pre-Authorization for evaluation has been
Transplants obtained.
Medically Necessary transplants are covered after the
applicable Cost-Share amount. The Cost-Share amount Transportation, Lodging And Meal Expenses For
depends on where the procedures are rendered. Transplants
Expenses for transportation, lodging and meals for the
The following organ transplants are covered: Member receiving the transplant and for one companion of
• Bone marrow, the Member are covered as described below.
• Cornea, The transplant facility must be located outside of
Connecticut and Massachusetts and be more than 50 miles
• Heart,
from where the Member receiving the transplant lives for
• Heart-lung, this reimbursement to apply.
• Intestinal, • Expenses may be submitted beginning with the date
• Kidney, the transplant evaluation began through 90 days after
the transplant was received.
• Liver,
• Transportation costs for travel to and from a
• Lung,
transplant facility for the Member receiving the
• Pancreas, and transplant and one companion are covered.
• Pancreas-kidney If air transportation is chosen, coverage includes
Bone marrow procedures such as autologous or allogeneic round trip coach class air fare for the Member
transplants, or peripheral stem cell rescue, or any procedure receiving the transplant and one companion up to
similar to these, are considered “organ transplants” under two round trips per person.
this Plan and are subject to its provisions. If a personal car is used, mileage will be paid based on
the federal Internal Revenue Code mileage
reimbursement rate at the time the travel was taken
for a maximum of two round trips to and from
where the Member receiving the transplant lives
to the transplant facility.
Page 33
• Lodging expenses for up to ten nights for the • The services in the Skilled Nursing
Member receiving the transplant and one companion Facility/Rehabilitation Facility must be provided
are covered up to the standard average room rate in directly by, or under the supervision of, a skilled
the city where the transplant is performed. health professional, and
• Meal expenses (excluding alcoholic beverages) for the • The admission must be Pre-Certified by us.
Member receiving the transplant and one companion There is no coverage for long term care or Custodial Care.
are covered up to two meals per day for a maximum
of ten days. BEHAVIORAL HEALTH (MENTAL HEALTH
In order for us to approve payment, transportation, lodging SERVICES)
and meal receipts must be sent to us at the appropriate Coverage for behavioral health (mental health services)
address listed in the information you will receive from us. under this Plan is administered under our Behavioral Health
There is no coverage for the following expenses: Program. Decisions regarding mental health coverage are
made by licensed mental health professionals.
• Any expenses for anyone other than the Member
receiving the transplant and one companion, Inpatient Mental Health Services
• Any expenses other than the transportation, lodging Medically Necessary inpatient mental Health Services, as
and meals described in this provision, defined in the most recent edition of the Diagnostic and
• Expenses over those described above, Statistical Manual of Mental Disorders (DSM), received in an
acute care Hospital or a Residential Treatment Facility, are
• Local transportation costs while at the transplant covered just as they would be for any other illness or injury
facility, and as described in the “Hospital Services” section.
• Rental car costs.
Inpatient Alcohol And Substance Abuse
Skilled Nursing And Rehabilitation Facilities Disorder Services
Medically Necessary skilled nursing care is covered up to Medically Necessary, medically monitored inpatient
the maximum benefit as shown in your Benefit detoxification services and Medically Necessary, medically
Summary if such care is provided: managed intensive inpatient detoxification services are
• At a Skilled Nursing Facility, covered just as they would be for any other illness or injury
as described in the “Hospital Services” section. Benefits also
• At an acute Rehabilitation Facility, or include coverage for Medically Necessary inpatient services,
• On a specialized inpatient rehabilitation floor in an supplies and medicine to treat substance abuse. These
acute care Hospital. treatments have the same meanings as described in the most
recent edition of the American Society of Addiction
Skilled Nursing And Rehabilitation Facilities Medicine Treatment Criteria for Addictive, Substance-
Limitations Related and Co-Occurring Conditions.
The following limitations and conditions apply to the Skilled
Nursing Facility/Rehabilitation Facility benefits: Substance abused disorder includes both alcohol
dependency, defined as meeting the criteria for moderate to
• In order to be covered, the skilled nursing care must severe alcohol use disorder in the most recent edition of the
be for intense rehabilitation or sub-acute medical Diagnostic and Statistical Manual of Mental Disorders
services, or a substitution for inpatient (DSM) and drug dependency, defined as meeting the criteria
Hospitalization, for moderate or severe Substance Abuse Disorder in the
• The care must be ordered by a doctor. The doctor’s most recent edition of DSM.
order must specify the skills of qualified health
professionals such as registered nurses, physical
therapists, occupational therapists, or speech
pathologists, required for the Member’s care in the
facility.
Admissions and continued stay requests will be
reviewed by us by using nationally recognized
measures to determine if the skilled nursing care will
result in significant functional gain or improvement to
the Member’s medical condition,
Page 34
Outpatient Mental Health And Alcohol And Behavioral Health Exclusions And Limitations
Substance Abuse Disorder Treatment There is no coverage for behavioral health conditions with
the following diagnoses:
Medically Necessary outpatient services for the diagnosis and
treatment of mental illnesses, as defined in the most recent • Caffeine-related disorders,
edition of the Diagnostic and Statistical Manual of Mental
• Communication disorders,
Disorders (DSM) are covered just as they would be for any
other illness or injury as described in the “Outpatient • Gambling disorders,
Services” section. Benefits also include coverage for • Learning disorders,
treatment for alcohol and substance abuse. The services
must be provided by a licensed mental health provider. • Mental retardation,
Pre-Authorization is required for some outpatient treatment • Motor skills disorders,
for mental health and alcohol and substance abuse services, • Relational disorders,
including office visits, subsequent to an evaluation. • Sexual deviation, or
Please refer to the “Pre-Authorization And Pre-Certification • Other conditions not defined as mental disorders in
(Prior Approval) Addendum” to find out what services the most recent edition of the Diagnostic and
require Pre-Authorizations. Statistical Manual of Mental Disorders (DSM).
Other Behavioral Health Benefits OTHER SERVICES
Chemical Maintenance Treatment Home Health Services
Chemical maintenance treatment is covered after the
Medically Necessary home health services must be provided
applicable Cost-Share amount, as prescribed by applicable
by a Home Health Agency and Pre-Authorized. Home health
law.
services are covered after the applicable Cost-Share
Evidence-Based Maternal, Infant And Early Childhood amount up to the maximum benefit as shown on the
Home Visitation Services Benefit Summary, if:
Evidence-based maternal, infant and early childhood home • We determine that Hospitalization or admission to a
visitation services that are designed to improve health Skilled Nursing Facility would otherwise be required,
outcomes for pregnant women, postpartum mothers and or,
newborns and children, including but not limited to services
for maternal substance use disorders or depression and • The Member is diagnosed as terminally ill and his/her
relationship-focused interventions for children with mental life expectancy is six months or less, or
or nervous conditions or substance abuse disorders are • A plan of home health care is ordered by a physician
covered after the applicable Cost-Share amount. and approved by us.
Extended Day Treatment Programs The home health services must be medical and
therapeutic health services provided in the Member’s
Extended day treatment programs are covered after the home, including:
applicable Cost-Share amount, as prescribed by applicable
law. ♦ Nursing care by a registered nurse or licensed
practical nurse,
Intensive, Family-Based And Community-Based
Treatment Programs ♦ Social services by a Masters-prepared social
worker provided to, or on behalf of, a terminally
Intensive, family-based and community-based treatment ill Member,
programs that focus on addressing environmental systems
that impact chronic and violent juvenile offenders are ♦ Physical, occupational or speech therapy;
covered after the applicable Cost-Share amount. ♦ Hospice care for a terminally ill patient (i.e., having
a life expectancy of six months or less), or
Other Home-Based Therapeutic Interventions For
Children ♦ Certain medical supplies, medications and
Home-based therapeutic interventions for children are laboratory services.
covered after the applicable Cost-Share amount.
Page 35
There is no coverage for: The following limitations and conditions apply:
• Custodial Care, • DME must be ordered by a physician.
• Convalescent care, Note: Having a doctor’s order is not a guarantee that
the DME is covered.
• Domiciliary care,
• Long term care, • The equipment must be provided by a DME
Participating Provider in order for the DME to be
• Rest home care, or covered at the highest level of benefits.
• Home health aide care that is not patient care of a • Some DME requires Pre-Authorization before it will
medical or therapeutic nature. be covered. The DME that requires Pre-
The benefit maximum does not apply to Hospice care. Authorization is listed in the “Services Requiring Pre-
Authorization Or Pre-Certification” section.
Disposable Medical Supplies And Durable • We reserve the right to limit the payment of charges
Medical Equipment (DME), Including up to the most cost efficient and least restrictive level
Prosthetics of service or item which can be safely and effectively
Disposable Medical Supplies provided.
Some, but not all, disposable medical supplies, which are • DME may be authorized for rental or purchase based
used with covered durable medical equipment or covered on the expected length of medical need and the
medical treatment received in the home, are covered after cost/benefit of a purchase or rental. We will decide
the applicable Cost-Share as shown on your Benefit whether DME is to be rented or purchased. If a rental
Summary. item is converted to a purchase, the Coinsurance the
Member pays for the purchase will be based on only
The following limitations and conditions apply: the balance remaining to be paid in order to purchase
• Disposable medical supplies must be ordered by a the equipment.
physician. • DME will be covered without Pre-Authorization if it
Note: Having a doctor’s order is not a guarantee that is dispensed in:
the disposable supplies are covered. ♦ A physician’s office as part of physician services,
• Disposable medical supplies will also be covered if ♦ An emergency room as part of Emergency
they are dispensed in: Services, or
♦ A physician’s office as part of the physician ♦ An Urgent Care Center as part of Urgent Care.
services, or
In these cases, DME will be covered as part of the
♦ An emergency room as part of Emergency DME, Emergency Services or Walk-In/Urgent Care
Services, or Centers benefit.
♦ An Urgent Care Center as part of Urgent Care. • Hearing aids are covered up to one hearing aid per
In these cases, the disposable medical supplies will be ear every 24 months.
covered as part of the Disposable Medical Supplies, • A wig prescribed by an oncologist for a Member
Emergency Services or Walk-In/Urgent Care Centers suffering hair loss as a result of chemotherapy or
benefit. radiation therapy are covered without Pre-
• We have the right to change the list of covered Authorization up to one wig per year.
disposable medical supplies from time to time. • To be covered, DME must not duplicate the function
Durable Medical Equipment (DME), Including of any previously obtained equipment.
Prosthetics
Durable Medical Equipment (DME) including prosthetics,
consists of non-disposable equipment which is primarily
used to serve a medical purpose and is appropriate for use in
the home. DME is covered after the applicable Cost-
Share is met, as shown on the Benefit Summary.
Page 36
Disposable Medical Supplies And Durable Medical • Power mobility devices, such as wheelchairs or
Equipment (DME), Including Prosthetics Exclusions scooters,
And Limitations • TENS units or other neuromuscular stimulators and
There is no coverage for medical supplies, equipment or related supplies, either internal or external, for the
prosthetics that are not durable or that are not on our list of treatment of pain or other medical conditions, and
covered equipment. Examples of excluded supplies and
• Wigs, hair prosthetics, scalp hair prosthetics or cranial
equipment include, but are not limited to:
prosthetics, except as otherwise described in this
• Any item not primarily medical in nature, subsection
• Any item or service which is not covered by the Ostomy Supplies And Equipment
Medicare or Medicaid programs,
Medically Necessary disposable medical supplies and durable
• Assistive technology and adaptive equipment, medical equipment for ostomy care are covered after the
including but not limited to: applicable Cost-Share amount described in your Benefit
♦ Communication boards, computers, equipment or Summary.
devices, Examples of covered ostomy supplies and equipment are:
♦ Gait trainers, collection devices, irrigation equipment and supplies, skin
barriers and skin protectors.
♦ Prone standers,
♦ Supine boards, and Ostomy Supplies Limitations
The following limitations and conditions apply to the ostomy
♦ Other equipment not intended for use in the supplies and equipment benefit:
home
• Beds, bedding and bed-related items, • Ostomy supplies and equipment must be prescribed
or ordered by a doctor as a result of surgery.
• Bone growth (osteogenic) stimulators (spinal, non-
spinal and ultrasonic), • To obtain the supply or equipment, the Member must
present the prescription or doctor’s order to the
• Clothing or bodywear, except as otherwise covered in provider that is selling the supply or equipment.
the “Benefits” section,
• Ostomy supplies or equipment will also be covered as
• Comfort or convenience items, including but not part of the Outpatient Services, Emergency Services
limited to: or Walk-In/Urgent Care Centers benefit if dispensed
♦ Furniture or modifications to furniture, in:
♦ Home climate control devices, or ♦ A doctor’s office as part of doctor services,
♦ Tubs, spas or saunas, ♦ An emergency room as part of Emergency
Services, or
• Compression and cold therapy devices,
♦ An Urgent Care Center as part of Urgent Care.
• Compression or anti-embolism stockings,
In the cases listed immediately above, the ostomy
• Cryotherapy; polar packs, supplies and equipment will be covered as part of the
• Exercise equipment, Outpatient Services, Emergency Services or Walk-
In/Urgent Care Centers benefit.
• Foot orthotics,
• Hearing aids, except as otherwise described in this
subsection,
• Home or automobile equipment or modifications,
• Items used to perform or assist with personal hygiene
• Lifts of any type,
• Mechanical stretch devices for treatment of joint
stiffness (pre- or post-surgery) or joint contractures,
• Myoelectric or electronic prosthetic devices,
• Pneumatic compression devices for the treatment of
lymphedema or the prevention of deep vein
thrombosis,
Page 37
ADDITIONAL SERVICES Cardiac Rehabilitation
Cardiac rehabilitation is covered after the applicable Cost-
Autism Services Share amount described in your Benefit Summary.
Medically Necessary diagnosis and treatment of Autism
Phase I cardiac rehabilitation is covered.
Spectrum Disorders (ASDs), identified and ordered in a
treatment plan developed by a licensed doctor, psychologist Medically Necessary Phase II cardiac rehabilitation is
or clinical social worker pursuant to a comprehensive covered if it is ordered by a doctor and received in a
evaluation are covered: structured setting.
• Behavioral Therapy, when provided or supervised by Coverage for Phase III cardiac rehabilitation is only available
a behavioral analyst who is certified by the Behavioral for Members who meet the rules for enrollment in our
Analyst Certification Board, or by a licensed doctor, HeartCare health management program and when the
or by a licensed psychologist. rehabilitation program is approved by us. See the “Health
Management Programs” section.
• Direct psychiatric or psychological services and
consultations provided by a licensed psychiatrist or by Phase IV Cardiac rehabilitation is not covered.
a psychologist.
Casts And Dressing Application
• Occupational, physical and speech/language therapy
provided by a licensed therapist. Application of casts and dressings is covered after the
applicable Cost-Share amount. The Cost-Share amount
This occupational, physical and speech/language depends on where the services are provided.
therapy benefit is not subject to any benefit maximum
for outpatient rehabilitative therapy listed on your Clinical Trials
Benefit Summary. Certain routine care for a Member who is a patient in a
• Prescription drugs when prescribed by a physician, by disabling or Life-Threatening chronic diseases clinical trial,
a doctor’s assistant or by an advanced practice such as for cancer, is covered just as routine care would be
registered nurse for the treatment of symptoms and covered under this Plan if the Member were not involved in
comorbidities of ASD, are covered as described in a disabling or Life-Threatening chronic diseases clinical trial.
the under our “Prescription Drugs” subsection of the All of the terms and conditions of this document apply.
“Benefits” section.
For the purposes of this clinical trials benefit, Life-
There is no coverage for special education and related Threatening means any disease or condition from which
services, except as otherwise described above. the likelihood of death is probable unless the course of the
disease or condition is interrupted.
Birth To Three Program (Early Intervention
Services) In order for the Member to be eligible for coverage, the trial
must be Pre-Authorized and must take place under an
Early intervention services consist of care as part of an
independent peer-reviewed protocol approved or funded by:
Individualized Family Service Plan as prescribed by State law
and are covered for a Member from his/her birth until • One of the National Institutes of Health,
his/her third birthday.
• The Centers for Disease Control and Prevention,
The Cost-Share amount depends on where the procedures
• The Agency for Health Care Research and Quality,
are rendered and will only apply if the Member is enrolled in
one of our HSA-compatible high deductible health plans • The Centers for Medicare & Medicaid Services,
(HDHPs). • A National Cancer Institute affiliated cooperative
Any benefit amount paid for early intervention services does group or the federal Department of Defense,
not: Department of Energy, or Department of Veterans
Affairs, or
• Count towards any benefit maximums this Plan may
have, except as permitted under the law, or • The federal Food and Drug Administration (FDA) as
part of an investigational new medication or device
• Negatively affect the eligibility of coverage under this application or exemption.
Plan to the child, the child’s parent or the child’s
Coverage includes Health Services at Non-Participating
family members who are Members under this Plan, or
Providers, if the treatment is not available at Participating
• Constitute a reason for us to rescind or cancel the Providers and is not paid for by the clinical trial sponsor.
Member’s coverage under this Plan. Payments made to Non-Participating Providers for clinical
trials will be made at no greater cost to the Member than if
the treatment were provided at Participating Providers.
Page 38
The Connecticut Insurance Department has issued a Craniofacial Disorders
standardized form that must be used when a Member asks us Medically Necessary orthodontic treatment and appliances
to cover routine care costs in a clinical trial. for the treatment of craniofacial disorders are covered for
Denials are subject to the State of Connecticut utilization Members age 18 and younger, if the treatment and
review external Appeal/Grievance program. appliances are prescribed by a craniofacial team recognized
by the American Cleft Palate-Craniofacial Association and if
We may require the following in order for a Member to be
Pre-Authorized by us. The Cost-Share amount depends on
considered for coverage:
where the services are provided.
• Evidence that the Member meets all of the selection
criteria for the trial, Diabetes Services
• Evidence that the Member has given appropriate All Medically Necessary laboratory and diagnostic tests for
informed consent to the trial diabetes and all Medically Necessary services, supplies,
equipment and prescription drugs when ordered by a doctor
• Copies of any medical records, rules, test results or for the treatment of diabetes (including treatment for routine
other clinical information used to enroll the Member foot care) are covered. The Cost-Share amount depends on
in the trial, where the services are provided.
• A summary of how the expected routine care costs
Education
would exceed the costs for standard treatment,
Outpatient self-management training for the treatment of
• Information about any items or services (including diabetes, if the training is prescribed by a licensed health care
routine care) that may be paid for by another entity, professional, is covered. The training must be provided by a
including the name of the company paying for the certified, registered or licensed health care professional
trial, and/or trained in the care and management of diabetes. The Cost-
• Any other information we may reasonably need to Share amount depends on where the training is provided.
review the request. Benefits cover:
There is no coverage for the following:
• Up to ten hours of initial training for a Member who
• Cost of Experimental Or Investigational medicines or is first diagnosed with diabetes for the care and
devices that are not exempt from new medicine or management of diabetes, including counseling in
device application by the Food and Drug nutrition and proper use of equipment and supplies
Administration, for the treatment of diabetes, and
• Costs for non-Health Services, • Up to four hours for Medically Necessary training and
• Costs that would not be covered by this Plan for a education as a result of an additional diagnosis by a
non-Experimental Or Investigational treatment, doctor of a major change in the Member’s symptoms
or condition that requires a change of his/her
• Facility, ancillary, professional services and medicine program of self-management of diabetes, and
costs paid for by grants or funding for the trial,
• Up to four hours for Medically Necessary training and
• Routine costs that are: education as a result of new techniques and treatment
♦ Experimental Or Investigational, for diabetes.
♦ Provided solely to satisfy data collection and Prescription Drugs And Supplies
analysis needs and that are not used in the direct Prescription drugs and supplies for the treatment of diabetes
clinical management of the Member, or are covered as described in the “Prescription Drugs”
♦ Services that are clearly inconsistent with widely subsection of the “Benefits” section, including its Cost-Share
accepted and established standards of care for a provisions. If a Member obtains these same supplies for the
particular diagnosis, treatment of diabetes from a supplier that is not a
Participating Pharmacy, the supplies are covered as described
• Transportation, lodging, food or other travel expenses in the “Disposable Medical Supplies” section.
for the Member or any family member or companion
of the Member
Corneal Pachymetry
Medically Necessary corneal pachymetry (measurement of
the thickness of the cornea) is covered after the applicable
Cost-Share amount. The Cost-Share amount depends on
where the test is rendered.
Page 39
Prescription drugs administered by a needle, which are not Eyeglasses And Contact Lenses
obtained from a doctor or from a Home Health Agency are Standard Medically Necessary prescription lenses, frames,
covered as described in the “Prescription Drugs” subsection and prescription contact lenses for Members under age 20
of the “Benefits” section. are covered up to the maximum benefit, as shown on
your Benefit Summary, as follows:
Drug Ingestion Treatment (Accidental)
Medically Necessary services needed to treat the accidental • One pair of eyeglasses (lenses and frames) per year, or
ingestion or consumption of a controlled drug are covered. • Contact lenses which include one fitting and set of
The Cost-Share amount depends on where the services are lenses per year.
provided.
There is no coverage for adults (Members age 20) and over
Drug Therapy (Outpatient/Home) for eyeglasses and contact lenses. In addition, there is also no
coverage for any non-standard prescription lenses, frames,
Medically Necessary Drug Therapy is covered after the
and prescription contact lenses, including tinted lenses, no
applicable Cost-Share amount. The Cost-Share amount
matter the age of the Member.
depends on where the Drug Therapy is rendered.
Some Drug Therapy requires Pre-Authorization. Genetic Testing
Drug Therapy services include all drugs administered by a Standard chromosome analysis is covered with no Pre-
licensed provider. Authorization. Some molecular genetic testing is covered
after the applicable Cost-Share amount when a Member
Eye Care has or is thought to have certain clinical genetic conditions
and when the genetic testing is Pre-Authorized. The Cost-
IMPORTANT: Share amount depends on where the tests are provided.
If you opt to receive optometric services or procedures Coverage for molecular genetic testing will be available only:
that are not covered benefits under this Plan, a
Participating Provider optometrist may charge you his 1. When the Member has obtained genetic counseling, and
or her usual and customary rate for such services or 2. An appropriate evaluation has been performed consisting
procedures. Prior to providing you with optometric of:
services or procedures that are not covered benefits, the
optometrist should provide you with a treatment plan • A complete history,
that includes each anticipated service or procedure to • A complete physical examination,
be provided and the estimated cost of each such service
• Conventional diagnostic studies, and
or procedure. To fully understand your coverage, you
may wish to review this document. • Three generation pedigree charts; and
3. When a diagnosis cannot be made using routine history,
Diseases And Abnormal Conditions Of The Eye physical examination and diagnostic testing and there
Medically Necessary medical and surgical diagnosis and remains the possibility of a genetic condition that will
treatment of diseases or other abnormal conditions of the affect the Member’s health, and
eye and structures next to the eye are covered after the
4. When the result of the molecular genetic testing will
applicable Cost-Share amount. This coverage includes
directly impact the Member’s treatment.
annual retinal eye exams for Members with an existing
condition of the eye, such as glaucoma or diabetic Only the following molecular genetic tests and/or
retinopathy. The Cost-Share amount depends on where the Fluorescein In-Situ Hybridization (FISH) tests will be
services are received. covered:
NOTE: Unless otherwise noted, molecular genetic
testing and FISH testing for any of these conditions
requires Pre-Authorization.
1. Specific molecular genetic screening or FISH tests
recommended by the American College of Medical
Genetics (ACMG) or the American Congress of
Obstetricians and Gynecologists (ACOG),
2. Specific molecular cancer genetic testing or FISH testing
recommended by the American Society of Clinical
Oncology (ASCO) or the National Comprehensive
Cancer Network (NCCN),
Page 40
3. Molecular genetic testing or FISH testing to guide Hospice Care
medication therapy for the treatment of lymphoma,
leukemia, and inflammatory bowel disease, Medically Necessary Hospice care is covered at the
applicable Inpatient Hospital Services, Including Room
4. Prenatal molecular genetic testing or FISH testing & Board or Home Health Services Cost-Share amounts
associated with chorionic villus sampling and/or as shown on your Benefit Summary, if the Member has a
amniocentesis recommended by a perinatologist, genetic life expectancy of six months or less and if the care is Pre-
counselor or geneticist and consistent with standard of Authorized or Pre-Certified by us. The Member’s doctor
care, must contact us to arrange Hospice care. Hospice care does
5. Molecular genetic testing or FISH testing for one of the not apply to any specific benefit maximums your Plan may
following genetic conditions: have. The Cost-Share amount depends on where the services
are provided.
• Colorectal Cancer Susceptibility,
• Cystic Fibrosis - Pre-Authorization not required, Hospital Care
• Factor V Leiden - Pre-Authorization not required, Visits a doctor makes to examine or treat a Member who is
hospitalized are covered.
• Fragile X - Pre-Authorization not required,
• Hereditary Breast and Ovarian Cancer Syndrome Infertility Services
(BRCA), Benefits
• Hereditary Hemochromatosis - Pre-Authorization Medically Necessary diagnostic and testing procedures and
not required, therapy needed to treat diagnosed Infertility are covered at
• Medullary thyroid cancer and multiple endocrine the applicable Cost-Share amounts, up to the limits
neoplasia type 2, MEN2 (RET), or described below, if Pre-Authorized by us.
• Prothrombin - Pre-Authorization not required, • Ovulation induction (to a maximum of four cycles).
6. Array-based molecular evaluations recommended by a • Intrauterine insemination (to a maximum of three
genetic counselor or geneticist for the evaluation of cycles per recipient, regardless of source).
developmental delay or birth defects. • Uterine embryo lavage, in-vitro fertilization (IVF),
In addition to these genetic testing services, some pre- gamete intra-fallopian transfer (GIFT), zygote intra-
implantation genetic testing in the setting of in-vitro fallopian transfer (ZIFT) or low tubal ovum transfer
fertilization (IVF), gamete intra-fallopian transfer (GIFT), (to a maximum of two cycles combined for all
zygote intra-fallopian transfer (ZIFT) and low tubal ovum procedures, with not more than two embryo
transfer procedures are covered. Please see the “Infertility implantations per cycle). These cycles are only
Services” subsection for more information. covered when the Member has been unable to
There is no coverage for: conceive or produce conception or sustain a
successful pregnancy through the less expensive and
• All other genetic testing services, as well as genetic medically appropriate treatments covered by this Plan.
testing panels not endorsed by ACMG, ACOG, A particular Infertility treatment or procedure need
ACSO or NCCN, not be tried first if the Member’s treating Board
• Genetic testing kits available either direct to the Eligible or Board Certified Reproductive
consumer or via a physician prescription, Endocrinologist certifies that such treatment or
procedure is unlikely to be successful.
• Genetic testing only for the benefit of another family
member, • Pre-implantation genetic testing is covered when
Medically Necessary and Pre-Authorized, as part of a
• Genetic testing to guide personalized medicine,
Pre-Authorized IVF, GIFT, ZIFT or low tubal ovum
• Pharmacogenetics or Pharmacogenomics, transfer procedure, if embryos are at risk for known
• Repeat genetic testing, and genetic mutations. Pre-implantation genetic testing to
determine the gender of an embryo is covered only
• Whole genome or whole exome genetic testing when there is a documented risk of an x-linked
disorder.
Page 41
• Prescription drugs (medications) to treat Infertility Lyme Disease Services
also require Pre-Authorization.
Medically Necessary treatment of Lyme Disease is covered
These drugs or medications are only available for the as follows:
gender indicated by the federal Food and Drug
Administration (FDA) and are covered as described • Up to a maximum of 30 days of intravenous antibiotic
in the “Prescription Drugs” subsection of the therapy or 60 days of oral antibiotic therapy, or both,
“Benefits” section. and
Rules • Further treatment if it is recommended by a board
certified rheumatologist, by an infectious disease
In order to obtain benefits for Infertility the following rules
specialist, or by a neurologist.
apply:
Antibiotic drugs are covered as described in the
1. For certain Infertility services, a Member must be treated “Prescription Drugs” subsection of the “Benefits” section.
by a board eligible or board certified reproductive
endocrinologist at a facility that meets the standards and Neuropsychological Testing
rules of the American Society of Reproductive Medicine Medically Necessary psychological, neuropsychological or
or the Society of Reproductive Endocrinology and neurobehavioral testing is covered only when performed by
Infertility. an appropriately licensed neurologist, by a psychologist or by
If you are enrolled in our POS Personal Care Plan (a a psychiatrist, to assess the extent of any cognitive or
Plan that requires Referrals), then services will not be developmental delays due to chemotherapy or radiation
covered, unless you obtain a Referral from your PCP to treatment in a child diagnosed with cancer.
the board eligible or board certified reproductive
endocrinologist. Nutritional Counseling
2. All services must be provided by the providers noted Coverage for nutritional counseling services is limited to two
above in order to be covered. visits per Member per year. Nutritional counseling must
be for illnesses requiring therapeutic dietary monitoring,
There is no coverage for: including the diagnosis of obesity. In addition, the services
• All Infertility services following voluntary sterilization must be prescribed by a licensed health care professional and
where no attempt at reversal has been made, provided by a certified, registered or licensed health care
professional.
• Cryopreservation (freezing) or banking of eggs,
embryos, or sperm, Nutritional Supplements And Food Products
• Genetic analysis and testing, except as otherwise Enteral Or Intravenous Nutritional Therapy
described above or in the “Genetic Testing” section,
Medically Necessary enteral (tube feeding) or intravenous
• Medicines for sexual dysfunction, nutritional products are covered at the applicable Cost-
• Recruitment, selection and screening and any other Share amount when ordered by a doctor, if they are needed
expenses of donors (donors of eggs, embryos or for a medical illness or injury, are to be used for the total
sperm), caloric needs of the Member.
• Reversal of surgical sterilization, and Oral nutritional products (except for Modified Food
Products For Inherited Metabolic Diseases and Other
• Surrogacy and all charges associated with surrogacy Specialized Formulas) that are specially changed to allow
such as prescription drugs, fertilization or them to be taken through an irregular gastrointestinal tract
implantation. are covered when:
• They are ordered by a doctor,
• They are needed due to a gastrointestinal illness or
injury preventing them from being taken normally;
and
• They are to be used for the total caloric needs of a
Member.
Page 42
Modified Food Products For Inherited Metabolic Pain Management Services
Diseases Medically Necessary pain management services provided by a
Medically Necessary modified food products (low protein) doctor (including evaluation and therapy) for short or long
and amino acid modified preparations are covered at the term pain conditions are covered after the applicable
Modified Food Products and Specialized Formulas Cost-Share amount.
Drug Cost-Share amount listed in your Benefit
Summary. The Cost-Share amount depends on where the services are
provided.
Modified food products and amino acid preparations are
covered for the treatment of the following inherited There is no coverage for:
metabolic diseases: • Automated percutaneous lumbar discectomy
• Biotinidase deficiency, (APLD)/automated percutaneous nucleotomy,
• Congenital adrenal hyperplasia, • Coblation Nucleoplasty™, disc nucleoplasty,
decompression nucleoplasty plasma disc
• Cystic fibrosis, decompression,
• Galactosemia, • Endoscopic anterior spinal surgery/Yeung
• Homocystinuria, endoscopic spinal system (YESS)/percutaneous
endoscopic diskectomy (PELD)/arthoroscopic
• Hypothyroidism,
microdiscectomy, selective endoscopic discectomy
• Inborn errors of metabolism, as described by the (SED),
Department of Public Health,
• Endoscopic disc decompression, ablation or annular
• Maple syrup urine disease, modulation using the DiscFX™ System,
• Phenylketonuria (for which newborn screening is • Endoscopic epidural adhesiolysis,
required), and
• Epiduroscopy, epidural myeloscopy, epidural spinal
• Sickle cell disease. endoscopy,
To be covered, the modified food products (low protein) and • Intradiscal and/or paravertebral oxygen/ozone
amino acid preparations must be ordered for the therapeutic injections,
treatment of one of the inherited metabolic diseases noted
above by a doctor and administered under his/her direction. • Intervertebral disc biacuplasty/cooled radiofrequency,
• Interdiscal electrothermal annuloplasty/Interdiscal
Other Specialized Formulas electrothermal therapy (IDET),
Specialized formulas are covered at the Modified Food
Products and Specialized Formulas Drug Cost-Share • Intralesional Anesthesia or Postoperative Disposable
amount listed in your Benefit Summary. Ambulatory Regional Anesthesia,
• Percutaneous laminotomy/laminectomy,
Specialized formulas are covered when the formula does not
percutaneous spinal decompression,
have to be part of the general nutritional labeling
requirements of the federal Food and Drug Administration • Percutaneous laser discectomy/decompression, laser-
and its intended use is solely for the dietary management of assisted disc decompression (LADD),
specific diseases or conditions. The formula must be • Percutaneous epidural adhesiolysis, percutaneous
Medically Necessary, ordered by a doctor and administered epidural lysis of adhesions, Racz procedure,
under his/her direction.
• Percutaneous intradiscal radiofrequency
Except as noted above, no other nutritional supplements, thermocoagulation (PIRFT), intradiscal
food supplements, infant formulas, enteral nutritional radiofrequency thermomodulation or percutaneous
therapies or specialized formula are covered. radiofrequency thermomodulation,
• Prolotherapy, and
• Spinal Distraction Systems.
Renal Dialysis
Medically Necessary renal dialysis for the treatment of kidney
disease is covered.
Page 43
Sleep Studies Reconstructive Surgery
Medically Necessary sleep studies are covered after the The following reconstructive surgery provided by a doctor
applicable Cost-Share amount. The Cost-Share amount and when Pre-Authorized is covered:
depends on where the services are provided. Coverage is
available for one complete study per lifetime when • Procedures to correct a serious disfigurement or
provided by a sleep facility or out-of-center sleep deformity resulting from:
organization that is accredited by the American Academy of ♦ Illness or injury,
Sleep Medicine (AASM) under the supervision of a board- ♦ Surgical removal of tumor, or
eligible or board-certified practitioner of Sleep Medicine. A
complete sleep study may include more than one session. ♦ Treatment of leukemia.
• Medically Necessary reconstructive surgery for the
Surgery And Other Care Related To Surgery correction of a congenital anomaly restoring physical
Medically Necessary surgery provided by a doctor is covered or mechanical use to that part of the Member’s body.
after the applicable Cost-Share amount. The Cost-Share Other reconstructive surgery for the correction of
amount depends on where the services are provided. Some congenital malformation is excluded. See the
surgical procedures require Pre-Authorization. The surgical “Exclusions And Limitations” section.
procedures that require Pre-Authorization are listed in the
“Services Requiring Pre-Authorization Or Pre-Certification” • Breast reconstructive surgery on each breast on which
section. a mastectomy has been performed and on a non-
diseased breast (in conjunction with reconstruction
Anesthesia Services after mastectomy) to produce a symmetrical
Anesthesia services as part of a covered inpatient or appearance.
outpatient surgical procedure provided by a doctor are
Sterilization
covered.
Male sterilization services provided by a doctor are covered
Breast Implants after the applicable Cost-Share amount. The Cost-Share
The surgical removal of any breast implant which was amount depends on where the procedures are provided.
implanted on or before July 1, 1994, no matter what the Female sterilization services provided by a doctor are
purpose of the implantation, is covered if the services are covered without any Cost-Sharing amount.
provided by a doctor. The surgical implantation of a
prosthetic device required in connection with the surgical Termination Of Pregnancy
removal of a breast due to a tumor is covered. Services for elective and non-elective termination of
pregnancy are covered after the applicable Cost-Share, as
Oral Surgery Services shown on your Benefit Summary, up to three elective
Medically Necessary oral surgical services for the treatment terminations of pregnancy per lifetime. The Cost-Share
of tumors, cysts, injuries of the facial bones and for the amount depends on where the procedures are provided.
treatment of fractures and dislocations involving the face and
jaw, including temporomandibular joint (TMJ) dysfunction Telemedicine Services
surgery (for demonstrable joint disease only) or When available in your area, Telemedicine services for the
temporomandibular disease (TMD) syndrome, provided by a purpose of advice, diagnosis, care or treatment are covered
doctor are covered. Oral surgery requires Pre-Authorization. in the same manner as an in-person service between you and
There is no coverage for non-surgical treatment of your provider. Telemedicine services include the use of real-
temporomandibular joint (TMJ) dysfunction or time interactive audio, video or other electronic media
temporomandibular disease (TMD) syndrome, including but telecommunications, and telemedicine services involving
not limited to: appliances, behavior modification, stored images forwarded for future services.
physiotherapy and prosthodontic therapy. Telemedicine services may make use of the following
technologies:
• A mobile application,
• The internet by a webcam, or
• The telephone.
Covered Telemedicine service technology must be able to
capture images and or health record information for use
during a service or afterward for the continuity of the
Member’s care.
Page 44
Telemedicine services are covered after the Cost-Share • Telemedicine services involving the use of electronic
amount, as shown on your Benefit Summary. The Cost- mail, facsimile, texting or audio-only telephone.
Share amount will be the same amount you would pay if the
service was provided through an in-person service between Wound Care Supplies
you and your provider. Medically Necessary wound care supplies (including wound
A Member may use any provider for telemedicine vacs) are covered when:
consultative services. However, to obtain the In-Network • Prescribed by a physician,
Level Of Benefits, you must use a provider who participates
as a Dedicated Virtual Network Provider. To locate a • Supplied by a participating health care provider or
Dedicated Virtual Network Provider, visit us at our web site Home Care Agency,
at www.connecticare.com, or call us. • Pre-Authorized by us, and
For the purpose of Telemedicine services benefit, • Provided in conjunction with authorized home care
Dedicated Virtual Network Provider means a provider or services
facility that has entered into an agreement with us, or with an If wound care supplies are not being provided in
organization contracting on our behalf, to deliver conjunction with authorized home care services then
Telemedicine services. the applicable Cost-Share amount will apply.
There is no coverage for the following expenses: Wound Care Supplies for Epidermolysis Bullosa
• Costs for asking for Pre-Authorizations or Pre- Medically necessary wound care supplies administered under
the direction of a physician for the treatment of
Certifications,
epidermolysis bullosa are covered with Pre-Authorization.
• Costs for diet counseling or prescriptions for Drug Supplies will be covered after the applicable Cost-Share
Enforcement Administration (DEA) controlled amount. The Cost-Share amount depends on where the
substances or lifestyle drugs, such as sexual supplies are obtained.
dysfunction, diet drugs or hair growth drugs,
• Costs for furnishing and/or receiving medical records HEALTH MANAGEMENT PROGRAMS
and reports, Health management programs are set up to help Members
manage their long term health conditions.
• Costs for getting answers to billing, insurance
coverage or payment questions, Members in this Plan may be eligible to enroll in one or
more of our health management programs. In addition,
• Costs for provider to provider discussions,
Members may be contacted and managed by our High Risk
• Costs for Referrals to providers outside the online Member Outreach Program.
care panel,
Depending on the programs that are available at the time, a
• Costs for reporting normal lab or other test results, Member may receive the following items or services as value
• Costs for requesting office visits, added services or covered benefits:
• Costs for research services by providers not directly • Educational mailings or visits,
responsible for your care, • Nicotine replacement therapy (NRT),
• Costs for services not documented in provider • Pillboxes, and
records,
• Special medical equipment such as a blood pressure
• Costs from an outside laboratory or shop for services monitor/cuff, a peak flow meter, a glucose monitor
in connection with an order involving devices (e.g., or a scale to assist during convalescence or to monitor
prosthetics, orthotics) which are manufactured by that a special medical condition
laboratory or shop, but which are designed to be
fitted and adjusted by the attending physician, When these items are covered benefits, they will not be
subject to standard claim processing and Cost-Sharing rules.
• Fees associated with data usage on a mobile phone or
fees for short message service (SMS)/text messaging, If you are enrolled in one of our HSA-compatible high
deductible health plans (HDHP), the health management
• Membership, administrative, or access fees charged by program items or services that are covered benefits are
physicians or other providers Examples of subject to the Plan Deductible. However, those items or
administrative fees include, but are not limited to: services may not be subject to the other Cost Share amounts
Fees charged for educational brochures or calling a that do apply after the Plan Deductible is satisfied.
patient to provide their test results, You can call our Member Services Department to find out
• Provider fees for technical costs or facility fees for the more about our current health management programs.
provision of Telemedicine services, and
Page 45
PRESCRIPTION DRUGS To be covered, prescription drugs must:
Benefits • Be Medically Necessary;

NOTE: Under federal law, we will permit certain • Be marketed in the United States at the time of
medications, certain over-the-counter (OTC) purchase, and
contraceptives and vitamins, as defined by the United • In most cases, bear the label: “Caution: Federal law
States Preventive Service Task Force , to be exempt prohibits dispensing without prescription.” (Please see
from Member Cost-Shares (Deductible, Copayment and the “Over-The-Counter (OTC) Medications”
Coinsurance). As a result, there may be times when you subsection to find out when OTC medications are
will not be required to pay the applicable Cost-Shares covered).
you usually pay for covered medications under your
Plan. Additional Benefits
Subject to all of the provisions of this Policy, including the Over-The-Counter (OTC) Medications
guidelines, and exclusions and limitations, benefits consist of Certain over-the-counter (OTC) medications are covered,
the following prescription drugs, medications, and supplies. subject to terms and conditions of this Policy and the
• All federal Food and Drug Administration (FDA) following:
approved prescription drugs. 1. The OTC medication must be an OTC medication that is
• All prescription contraceptive methods approved by required to be covered under the PPACA. The OTC
the federal FDA, including, but not limited to: medications that we will cover are listed on our web site
at www.connecticare.com.
♦ Cervical caps,
2. You must obtain a prescription for the OTC medication
♦ Diaphragms, from your doctor.
♦ Intrauterine Devices (IUDs), and 3. The OTC medication must be filled as a prescription at a
♦ Oral contraceptives pharmacy by the pharmacist; otherwise it will not be
NOTE: Covered at no Cost-Share when they are covered.
obtained at a Participating Pharmacy. Prescription 4. When such OTC medications are covered, they will be
contraception is NOT covered under this Plan if covered based upon age, gender and/or disease required
specified on your Benefit Summary. to be covered under the PPACA.
• For the treatment of Lyme Disease: up to 30 days of The Cost-Share amounts you are required to pay for
intravenous antibiotic therapy or up to 60 days of oral prescriptions are found on your Benefit Summary.
antibiotic therapy, or both, and further treatment if
recommended by a board certified rheumatologist
The list of OTC medications may change at any time.
specialist, infectious disease specialist or neurologist. When the list does change, you will be notified in our
• Injectable drugs, provided that they are obtained at a member newsletter. You should call our Member
pharmacy and all of the other rules of this Policy are Services Department at the telephone number listed in
followed. the “Important Telephone Numbers And Addresses”
NOTE: Orally administered anticancer drugs shall be section (or visit us at our web site at
covered no less favorably than the intravenous www.connecticare.com) to find out if an OTC
administration of injectable anticancer drugs are, where medication is covered under this Policy. We have the
consistent with applicable federal law. right to change the OTC medications on the list.
• Insulin and the following supplies: Specialty Drugs
Specialty drugs are those prescription drugs that are not
♦ Acetone/ketone testing agents,
needed immediately to treat a sudden medical condition, and
♦ Blood and urine glucose testing agents, that require:
♦ Injectable syringes and needles, and • A higher level of pharmacy expertise,
♦ Lancets • Increased patient knowledge to administer, and
• Special handling.
In addition, specialty drugs are not typically stocked in a
retail pharmacy.
Page 46
Certain specialty prescription drugs require Pre- Guidelines
Authorization. You can find out the specialty drugs that
require Pre-Authorization by calling our Member Services In addition, to be covered, all prescription drugs and supplies
Department at the telephone number listed in the must meet the following rules and guidelines.
“Important Telephone Numbers And Addresses” section or When you bring your prescription to the pharmacy to be
visiting us at our web site at www.connecticare.com. filled, that submission of the prescription to the
Specialty drugs that require Pre-Authorization should be pharmacy does not represent a “claim” for coverage
filled through the specialty pharmacy we advise you of. under this Plan. Requests for coverage or Pre-
Authorization must be made directly to us to be
When you or your provider contacts us for Pre- considered a claim under the Plan.
Authorization of a specialty drug, if Pre-Authorization is
granted, you or your provider will be notified of the Certain Prescription Drugs/Supplies Require Pre-
telephone number to call to contact the specialty pharmacy. Authorization
Specialty drugs, when Pre-Authorized by us, will be Certain prescription drugs and supplies require Pre-
dispensed for a maximum of 30-day supply per fill. The Authorization from us before they will be covered. In
drugs will be shipped to your doctor’s office, your home, or addition, any drug that is newly available to the market will
other location based on the type of drug or treatment. also require Pre-Authorization until such time that we re-
publish our list of drugs that require Pre-Authorization. You
NOTE: Even though up to a 30-day supply of a can find the list of prescription drugs that need Pre-
specialty drug may be delivered by mail to you, or your Authorization at the back of this document.
provider’s office or some other location, specialty drugs
DO NOT have the same Cost-Share that applies to the Updates to the list of drugs or supplies requiring Pre-
Voluntary Mail Order program. Instead, specialty drugs Authorization are also published from time to time in
have the applicable retail pharmacy Cost-Share amount our member newsletter. You should call our Member
listed on your Benefit Summary. Services Department at the telephone number listed in
Specialized counseling and education are available to you the “Important Telephone Numbers And Addresses”
from the specialty pharmacy regarding proper administration, section (or visit us at our web site at
storage, dosage, drug interactions, and side effects of these www.connecticare.com) to find out if a prescription
specialty drugs. drug or supply requires Pre-Authorization. We have the
right to change the drugs or supplies on the list.
If the specialty drug is not available at the specialty pharmacy
we advised you of, or you are out of a specialty drug or if the When A Participating Provider Writes A Prescription
specialty drug ordered by your provider does not arrive in When a Participating Provider writes the prescription for the
time, we will authorize the specialty drug for up to a 30-day drug or supply, it is the responsibility of the Participating
supply at an alternate specialty pharmacy, so you can obtain Provider to obtain the Pre-Authorization, but you should
the needed medication. In this instance, you will not be check with your health care practitioner to make sure he or
required to pay any additional amounts above the normal she has obtained Pre-Authorization BEFORE you go to the
Cost-Share amounts you would typically pay for a specialty pharmacy.
drug under this Plan. When a prescription drug or supply requiring Pre-
You can find the list of specialty drugs that need Pre- Authorization is not Pre-Authorized, it will be rejected by
Authorization at the back of this document. the pharmacy.
Updates to the list of specialty drugs requiring Pre- If the prescription drug or supply is filled, benefits available
Authorization are also published from time to time in under this Plan will not be reduced or denied if the
our member newsletter. You should call our Member Participating Provider fails to request Pre-Authorization.
Services Department at the telephone number listed in However, when you submit that claim for reimbursement,
the “Important Telephone Numbers And Addresses” we will review it for Medical Necessity. If we determine that
section (or visit us at our web site at the prescription drug or supply was not Medically Necessary,
www.connecticare.com) to find out if a specialty drug re-fills of that prescription drug or supply will not be
requires Pre-Authorization. We have the right to change covered.
the specialty drugs on the list.
Page 47
When A Non-Participating Provider Writes A Using A Participating Pharmacy
Prescription When you and your Eligible Dependents use a Participating
It is your responsibility to obtain Pre-Authorization Pharmacy, the out-of-pocket Cost-Share amount you pay is
from us if a Non-Participating Provider writes your lower than what you would have to pay if you were to use a
prescription. Non-Participating Pharmacy.
When a prescription drug or supply requiring Pre- To reduce your out-of-pocket costs, use a Participating
Authorization is not Pre-Authorized, it will be rejected by Pharmacy.
the pharmacy. If the prescription drug or supply is filled and To locate a Participating Pharmacy, you can refer to our
you submit a claim to us for reimbursement, you should Provider Directory, visit us at our web site at
request your Non-Participating Provider to ask us for Pre-
www.connecticare.com, or call us.
Authorization. When that occurs we will review the claim for
Medical Necessity. If we determine that the prescription drug Using A Non-Participating Pharmacy
or supply was Medically Necessary and Pre-Authorization is When you use a Non-Participating Pharmacy for
then granted, we will reimburse you for the prescription drug prescriptions, you and your Eligible Dependents will still
or supply, which may be subject to the Benefit Reduction have coverage, but the out-of-pocket costs will be higher
provisions described in the “Managed Care Rules And than they would be if you were to use a Participating
Guidelines” section of this Policy. If we determine that the Pharmacy.
prescription drug or supply was not Medically Necessary,
that prescription drug or supply will not be covered. Your Benefit Summary will tell you Cost-Share amount
you are required to pay.
When Pre-Authorization is obtained, it is your responsibility
to make sure the authorization is still applicable when you go Prescription Drug Programs
to the pharmacy to have your prescription filled. If the The following provisions apply to our Prescription Drug
authorization was for a time period that expired you will Programs. To determine which programs apply to your Plan,
have to pay for the prescription. If the authorization was for consult your Benefit Summary.
an amount of drugs that is less than your prescription, your
prescription will be filled at the amount of drugs that was Generic Substitution Program
Pre-Authorized. 1. This Plan has the “Generic Substitution Program.” This
program applies to prescriptions filled at Participating
Always Use Your ID Card Pharmacies (retail or specialty pharmacies) and our
You and your covered dependents are required to use the designated mail order vendor.
ConnectiCare ID card when obtaining a prescription drug or
2. This Plan covers Generic Drugs Or Supplies when they
covered supply. In the event you do not use your ID card,
are available.
you will be charged the discount lost because the
prescription drug or covered supply was processed without Even if you request a covered Brand Name Drug Or
the ID card, in addition to any Cost-Share amount or other Supply and/or even if your provider deems a covered
charge due under this Plan. Brand Name Drug Or Supply to be Medically Necessary
and therefore prescribes a covered Brand Name Drug Or
Pharmacy Network Supply, where a Generic Equivalent drug or supply is
Under this Plan, you are free to use either Participating available, you will pay the difference in the cost between
Pharmacies or Non-Participating Pharmacies to obtain the Brand Name Drug Or Supply and the Generic
covered prescription drugs, medications, and supplies; Equivalent drug or supply, plus any applicable Cost Share
however you will pay different levels of Cost-Shares amount. When you are required to pay the difference in
(Copayments, Coinsurance, and/or Deductibles) depending price between the Generic Equivalent drug or supply and
on the pharmacy that dispenses the covered prescription the Brand Name Drug Or Supply that you obtained, that
drugs, medications, and supplies. amount DOES NOT accrue towards any Deductibles or
Out-Of-Pocket Maximum your Plan may have.
This table highlights the way the Participating Pharmacies
network works and the costs you will have. Your Benefit In some plans, the Cost-Share amount for a Brand Name
Summary will tell you the Cost-Share amount you are Drug Or Supply is the same as the Cost-Share amount
required to pay. for a Generic Drug Or Supply.
If You Use A You Have
Participating Pharmacy Lower Member Cost
Non-Participating Pharmacy Highest Member Cost
Page 48
Participating Pharmacies have information about Brand We have the right to change the drugs (including
Name Drugs Or Supplies with Generic Equivalents that certain OTC medications) or supplies in each tier, even
are required to be substituted. You should call our in the middle of the year. You should call our Member
Member Services Department at the telephone number Services Department at the telephone number listed in
listed in the “Important Telephone Numbers And the “Important Telephone Numbers And Addresses”
Addresses” section (or visit us at our web site at section (or visit us at our web site at
www.connecticare.com) to find out if a drug or supply www.connecticare.com) to find out which tier (if any) a
is covered. We have the right to change the drugs or prescription drug or supply is in.
supplies that are required to be substituted. Mandatory Drug Substitution Program
Pay The Difference Waiver 1. This Plan has a “Mandatory Drug Substitution Program.”
Some plans have the Pay The Difference Waiver as part of This program applies to prescriptions filled at
the Generic Substitution Program. To determine whether Participating Pharmacies, (retail pharmacies) and our
your Plan uses this waiver, consult your Benefit Summary. designated mail order vendor. It DOES NOT pertain to
prescriptions the Member receives to treat pain
When this waiver applies, in most plans we will cover the
Brand Name Drug Or Supply at the applicable Cost-Share management.
amount, when your physician requests the Brand Name 2. Prescription drugs that are on our “Mandatory Drug
Drug Or Supply on the prescription, without you having to Substitution” list are not covered, except as described
pay the difference in price between the Brand Name Drug below. Instead, another drug that has the same active
Or Supply and the Generic Equivalent drug or supply. ingredient as the excluded drug, but which is made by a
different manufacturer or sold by a different distributor,
Tiered Cost-Share Program will be covered. (The inactive ingredients may differ in
1. This Plan has a “Tiered Cost-Share Program.” This the drugs. Active ingredients are those ingredients with a
program applies to prescriptions filled at Participating therapeutic effect. Inactive ingredients are those
Pharmacies, (retail pharmacies), our designated mail order ingredients with no therapeutic effect.)
vendor, or specialty pharmacies, as well as those OTC 3. If your physician prescribes the excluded drug that is on
medications covered under this Plan (please refer to the the “Mandatory Drug Substitution” list, the Participating
“Over-The-Counter (OTC) Medications” subsection). Pharmacy will switch the prescription or call your
2. Under this program covered prescription drugs (including physician to receive authorization, if needed, to make the
certain OTC medications) and supplies are put into change to the covered drug from the excluded drug that
categories (i.e., “tiers”) to designate how they are to be was prescribed for you.
covered and the Member’s Cost-Share. The placement of 4. In certain cases, this Plan will cover the excluded drug on
a drug or supply into one of the tiers is determined by the the “Mandatory Drug Substitution” list if we determine
ConnectiCare Pharmacy Services Department and that, because of your or your covered dependent’s
approved by the ConnectiCare Pharmacy & Therapeutics adverse reaction to the covered drug or the covered
Committee based on the drug’s or supply’s clinical drug’s ineffectiveness for the Member, the excluded drug
effectiveness and cost, not on whether it is a Generic is Medically Necessary. We will make this determination
Drug Or Supply or Brand Name Drug Or Supply. based on clinical evidence presented by your physician to
The Cost-Share amount for a drug that is designated on us.
the first tier is generally the lowest amount you will pay 5. We will also cover excluded drugs which are added to the
for a prescription. Conversely, if a drug or supply is put “Mandatory Drug Substitution” list, if the following
into a higher tier designation, you will generally have to conditions are met:
pay more for that prescription. If a covered drug is in a
higher tier designation, that doesn’t mean it’s not a good • You were obtaining, through your coverage under the
drug or that you shouldn’t get it. It just means that you Plan, the excluded drug for the treatment of a chronic
will have to pay more for it. If your Plan has a illness prior to it being added to the “Mandatory Drug
prescription drug Benefit Deductible this may not always Substitution” list, and
be the case for particular prescriptions. • Your doctor provides to us a written statement that
In some plans, the Cost-Share amount from tier to tier is the excluded drug is Medically Necessary and includes
the same as the Cost-Share amount for another tier the reasons why the excluded drug is more medically
designation. beneficial in treating your chronic illness than the
In some plans with this program, you must pay a higher drugs that are covered under the Plan.
amount in addition to the Cost-Share amount, when you
obtain a Brand Name Drug Or Supply when there is a
Generic Equivalent.
Page 49
The drugs on the “Mandatory Drug Substitution” list 6. If you have a prescription that for any reason cannot be
are published from time to time in our member filled by our designated mail order vendor and you need
newsletter. You should call our Member Services to use a retail pharmacy to fill it instead, the retail
Department at the telephone number listed in the pharmacy Cost-Share amount found on your Benefit
“Important Telephone Numbers And Addresses” Summary applies.
section (or visit us at our web site at We have the right to change or limit the drugs eligible
www.connecticare.com) to find out if a prescription for dispensing through this program, even in the middle
drug is on this list. We have the right to change the of the year. You should call our Member Services
drugs on this list. Department at the telephone number listed in the
Mandatory Drug Limitations Program “Important Telephone Numbers And Addresses”
For some drugs, we will cover only a limited number of section to receive a list of drugs or drug classes
dosages per prescription and/or time period for the drug. ineligible for dispensing through this program.
These are drugs where we have determined, that the number Clinically Equivalent Alternative Drugs Or Supplies
of dosages available for the drug should be limited in Program
accordance with the proper medical use of the drug. We will 1. This Plan has the “Clinically Equivalent Alternative Drug
make these determinations based on the drug manufacturer’s Or Supplies Program.” This program applies to
suggestions, federal FDA guidelines and medical literature, prescriptions filled at retail or specialty pharmacies and
with input from physicians. our designated mail order vendor.
In certain cases, this Plan will cover additional units above 2. The Clinically Equivalent Alternative Drugs Or Supplies
the limited number of dosages per prescription and/or time Program includes a limited list of drugs and supplies that
period for the drug if we determine, that, because of your or are covered under this Plan that have been reviewed and
your covered dependent’s condition, these additional units recommended for use based on their quality and cost
are Medically Necessary. We will make this determination effectiveness.
based on clinical evidence presented by your physician to us.
When this occurs, you may be required to pay the applicable The list of covered Clinically Equivalent Alternative
Cost-Share amount. Drugs Or Supplies is based on clinical findings and cost
review. The clinical and cost review of the drug or supply
In addition, we reserve the right to designate that certain is, in most case, relative to other drugs or supplies in their
prescriptions be filled or refilled for no more than a 30-day therapeutic class or used to treat the same or a similar
supply at a time, regardless of whether your Benefit condition.
Summary has a fill or refill limit. When coverage is limited to
In addition, the list is also based on the availability of
a 30-day supply at a time for a drug, you will not be able to
over the counter medications, Generic Drugs Or
purchase that drug through our Voluntary Mail Order
Supplies, the use of one drug or supply over another by
Program.
our Members, and where proper, certain clinical
Voluntary Mail Order Program economic reasons.
1. This Plan has a “Voluntary Mail Order Program.” Generally, the program includes select Generic Drugs Or
2. Under the Voluntary Mail Order Program, you and your Supplies with limited Brand Name Drugs Or Supplies
covered dependents may fill your prescriptions at our that are covered under this Plan.
designated mail order vendor. 3. When a drug or supply is not on the Clinically Equivalent
3. You and your covered dependents may obtain up to a 90 Alternative Drugs Or Supplies list, it is excluded from
or 100-day supply of prescription drugs or covered coverage, unless it is Medically Necessary.
supplies through our designated mail order vendor. In order for the excluded drug or supply to be Medically
Please refer to your Benefit Summary to see the day Necessary, your provider must substantiate to us, in
supply limit and Cost-Share amounts for your Plan. writing, a statement that includes the reasons why use of
4. If your Plan requires a Deductible, you must make the drug or supply is more medically beneficial than a
payment arrangements with the Voluntary Mail Order Clinically Equivalent Alternative Drug or Supply.
Program vendor to fill prescriptions by mail when your The covered drugs and supplies are displayed on our
Deductible has not yet been satisfied. The telephone web site. You should call our Member Services
number to call for assistance is 1-800-369-0675. Department at the telephone number listed in the
5. To obtain these benefits, your physician must prescribe “Important Telephone Numbers And Addresses”
the 90 or 100-day supply of the prescription drugs or section (or visit us at our web site at
covered supplies. Detailed information about how to use www.connecticare.com) to find out if a prescription
the mail order program is provided to you in a separate drug or supply is on this list. We have the right to
flyer. change the drugs or supplies on the list.
Page 50
Cost-Share Waiver Programs 3. When a Deductible and Copayment or Coinsurance
From time to time, we may offer programs to support the applies, you must pay the Copayment amount, as
use of more cost-effective or clinically effective prescription described in paragraph 1, above, or the Coinsurance
drugs, including Generic Drugs, home delivery drugs over amount up to your Deductible amount. Then, once the
the counter drugs and preferred products. Those programs Deductible has been met, you will be responsible to pay
may reduce or waive Cost-Shares for a limited time that you the applicable Cost-Share amount listed on your Benefit
would otherwise pay under the terms of this Plan. Summary for each prescription, plus any applicable cost
difference. The Coinsurance amount is based on the rate
Member Cost-Sharing we would pay for the prescription.
You and your covered dependents are required to pay a If you have a Plan with a drug Benefit Deductible and
Cost-Share amount for covered prescription drugs and then a Copayment where you fulfill the Deductible
supplies obtained under this Plan. The Cost-Share amounts requirement in a particular claim, you will pay the
you are required to pay for prescriptions are found on your remaining Deductible amount for that year in addition to
Benefit Summary. the remaining drug cost up to the drug’s applicable
Copayment amount, described in paragraph 1, above.
1. If you have a Plan that requires a prescription drug
benefit Copayment, you will be required to pay the lesser 4. In some plans, a different type of Cost-Share applies
of the following: depending on which tier a drug or supply is in. For
example, you may have to pay a Copayment for a tier one
• The applicable Copayment amount for the drug or drug or supply and a Coinsurance for drugs or supplies
supply, or on a different tier.
• The amount we would pay for the drug or supply, or 5. Amounts paid by Members as their Coinsurance
• The amount you would pay for the drug or the supply responsibility, or due to any reduction in benefits do not
if you had purchased it without using the benefits of count towards meeting the Benefit Deductible.
this Plan.. 6. Amounts paid by Members because they must pay a price
2. If you have a Plan that requires a prescription drug difference for a Brand Name Drug do not count towards
Benefit Deductible, the Deductible amount must be met meeting any Deductible, Coinsurance, Copayment, or
in any calendar year for prescriptions subject to the Pharmacy Coinsurance Maximum.
prescription drug Benefit Deductible before we will begin
paying for those prescriptions. Under certain options, Benefit Limits
you will not be required to meet the Deductible amount Fill Or Refill Limit
if you obtain Generic Drugs Or Supplies. This Plan limits benefits for prescriptions filled or refilled at
A Benefit Deductible is considered to be met for a a retail pharmacy to a 30-day supply at a time. This Plan also
Member if the individual Deductible is met by the limits benefits for prescriptions filled or refilled through the
amounts paid for that Member for prescriptions covered Voluntary Mail Order Program to a 90-day supply at a time.
by the Deductible.
Lyme Disease Treatment Limit
A family Benefit Deductible amount (two Members) is
Antibiotic therapy for the treatment of lyme disease is
met for each Member when each Member separately
limited to 30 days of intravenous antibiotic therapy and 60
meets the individual Deductible amount.
days of oral antibiotic therapy, unless further treatment is
A family Benefit Deductible amount (three or more recommended by a board-certified rheumatologist, infectious
Members) is met by combining the total expenses for disease specialist or neurologist.
prescriptions contributed by each family member,
whereby no one family member incurs more than the
individual Member Deductible amount, up to the family
Deductible amount.
The Deductible does not apply to any other Deductible
amount you may be required to pay for Health Services
under the Plan.
Page 51
Prescription Drug Exclusions And Limitations 13. Prescription contraceptive methods used in connection
with birth control, if specified on your Benefit Summary.
There is no coverage for:
14. Prescription drugs or supplies:
1. All drugs or medications in a therapeutic drug class if one
of the drugs in that therapeutic drug class is not a • Covered by workers’ compensation law or similar
prescription drug, unless the drugs or medications are laws, or covered by workers' compensation coverage,
Medically Necessary. even if you choose not to claim those benefits, subject
to applicable state law,
2. Antibacterial soap/detergent, shampoo, toothpaste/gel,
or mouthwash/rinse. • Dispensed before the Member’s effective date or after
his or her termination date,
3. Any treatment, device, drug or supply to increase or
decrease height or alter the rate of growth, including • Dispensed in a Hospital or other inpatient facility,
devices to stimulate growth, and growth hormones. • Dispensed or prescribed in a manner contrary to
4. Appliances or devices, except as otherwise required by normal medical practice,
applicable law. • Furnished by the United States Veterans'
5. Certain prescription drugs and supplies are no longer Administration,
covered when Clinically Equivalent Alternative Drugs Or • Not required for the treatment or prevention of
Supplies are available unless otherwise required by law, or illness or injury,
are otherwise determined by us to be Medically
Necessary. In order for that drug or supply to be • Obtained for the use by another individual,
considered Medically Necessary, the provider who wrote • Obtained from outside of the United States by any
the prescription must substantiate to us, in writing, a means,
statement that includes the reasons why use of the drug
• Provided in connection with treatment of an
or supply is more medically beneficial than the Clinically
occupational injury or occupational illness, subject to
Equivalent Alternative Drug Or Supply.
applicable state law,
6. Compounded prescriptions, unless at least one ingredient
• Refilled in excess of the number the prescription calls
in the compounded prescription is FDA approved and
for, or refilled after one year from the date of the
the FDA component(s) of the compound is covered.
order for the prescription drug,
7. Drugs or medications if they include the same active
ingredient or a modified version of an active ingredient • Re-packaged in unit dose form,
and they are: • Unless the drug is included on the preferred drug
guide (formulary) or a medical exception is granted,
• Therapeutically equivalent or therapeutically an
alternative to a covered prescription drug, or • Used for or in preparation of Infertility treatment that
is not specifically covered under this Policy, including
• Therapeutically equivalent or therapeutically an
but not limited to Experimental or Investigational
alternative to an over-the-counter (OTC) product.
Infertility procedures,
This exclusion does not apply if the drugs or medications
are determined to be Medically Necessary. • Used for the purpose of weight gain or reduction,
obesity, including but not limited to stimulants,
8. Drugs or preparations, devices and supplies to enhance preparations, foods or diet supplements, dietary
strength, physical condition, endurance or physical regimens and supplements, food or food
performance, including performance enhancing steroids. supplements, appetite suppressants and other
9. Drugs that are lost, stolen, or damaged after they are medications,
dispensed by the pharmacy will not be replaced. • Used for travel,
10. Drugs that may be purchased without a prescription, • Used in connection with or for a Cosmetic Treatment
including prescription drugs with non-prescription OTC or hair loss, including but not limited to health and
equivalents, unless the prescription version of the over beauty aids, chemical peels, dermabrasion treatments,
the counter equivalent is determined to be Medically bleaching, creams, ointments or other treatments or
Necessary or as otherwise described in this Policy. supplies, to remove tattoos, scars or to alter the
11. Infant formulas, dietary or food supplements, appearance or texture of the skin, and
prescription medical foods and nutritional supplies, • Not suggested for use by manufacturers or not
except as described in the "Nutritional Supplements And approved by the federal FDA or our Pharmacy and
Food Products" subsection of the “Benefits” section and Therapeutic Committee, unless they are Medically
this “Prescription Drug” subsection. Necessary.
12. Medications for sexual dysfunction.
Page 52
15. Smoking cessation products, except as described in your Prescription Drug General Conditions
Benefit Summary, or to treat nicotine addiction.
1. We will not be liable for any injury, claim, or judgment
For nicotine addiction treatment, the product must be resulting from the dispensing of any prescription drug
obtained with a prescription and Pre-Authorized. covered by this Plan.
In addition, we may also cover smoking cessation 2. We may use a third party administrator to administer the
products if: benefits available under this Plan.
• The Member is being actively case managed, and 3. All claims must be submitted to us within 180 days from
• The use of the smoking cessation product is approved the date the drug or supplies were received with the
by us. appropriate claim form and as described in the “Claims
Filing, Questions And Complaints, And Appeal Process”
When those conditions are met, smoking cessation
section, “Claims Filing” subsection.
products may be provided as part of a health
management program value-added service or as a benefit. You can call our Member Services Department at the
telephone number listed in the “Important Telephone
16. Vitamins, minerals, hematinics and supplements, except
Numbers And Addresses” section to obtain the
prescription pre-natal vitamins or as otherwise described
appropriate claim form.
in this Policy.
4. Covered prescription drugs will not be denied as
Exception Review For A Non-Covered Experimental Or Investigational if the drug has
Clinically Appropriate Drug successfully completed a Phase III clinical trial conducted
You, your designee or your prescribing provider may request by the federal Food and Drug Administration (FDA).
a review of a request for a clinically appropriate drug not 5. We may require the Member’s treating physician to
covered by this Plan. If there are exigent circumstances, an furnish us with any information about the diagnosis or
expedited review may be requested. If there are not exigent prognosis of any injury or illness related to a prescription
circumstances, the review request will be treated as a drug and about the nature, quality, and quantity of the
standard (non-exigent circumstances) review. prescription drug prescribed in order to determine its
Medical Necessity.
Expedited Review (Exigent Circumstances)
6. Upon approval of new medications by the federal FDA,
1. Exigent circumstances exist when a Member is suffering
we reserve the right to implement Pre-Authorization
from a health condition that may seriously jeopardize
criteria and to set quantity limits to promote appropriate
his/her life, health, or ability to regain maximum function
use and to avoid abuse.
or when he/she is undergoing a current course of
treatment using a non-formulary drug. 7. We do not generally coordinate benefits under this Plan.
However, If you or your covered dependent have the
2. We must make our coverage determination on an
Medicare Part D Drug program, Medicare is the primary
expedited review request based on exigent circumstances
plan over this Plan.
and notify you or your designee and the prescribing
provider of our coverage determination no later than 24 8. We reserve the right to designate that certain
hours after we receive the request. prescriptions be filled or refilled for no more than a 30-
day supply at a time. When coverage is limited to a 30-
3. When we grant an exception based on exigent
day supply at a time for a drug, you will not be able to
circumstances, we will provide coverage of the non-
purchase that drug through our Voluntary Mail Order
formulary drug for the duration of the exigency.
Program.
Standard Review (Non-Exigent Circumstances)
1. We must make our coverage determination on a standard
(non-expedited) review and notify you or your designee
and the prescribing provider of our coverage
determination no later than 72 hours after we receive the
request
2. When we grant an exception based on non-exigent
circumstances, we will provide coverage of the non-
formulary drug for the duration of the prescription,
including refills.
Page 53
EXCLUSIONS AND LIMITATIONS 8. Benefits for services rendered before the Member's
Effective Date under this Plan or after the Plan has been
The following is a list of services, supplies, etc., that are rescinded, suspended, canceled, interrupted or
excluded and/or limited under this Plan. These exclusions terminated, except as otherwise required by the law.
and limitations supersede and override the “Benefits”
section, so that, even if a health care service, supply, etc. 9. Blood, blood products and related expenses.
seems to be covered in the “Benefits” section, the following 10. Cardiac rehabilitation for Phase III, unless the Member:
provisions will exclude or limit it.
• Meets the criteria for enrollment into our HeartCare
1. Abdominoplasty, lipectomy and panniculectomy. health management program,
2. All assistive communication devices. • Is being actively case managed, and
3. Ambulance services that are non-Emergency medical • The rehabilitation is approved by us.
transport services or chair car to and from a provider’s
Phase III Cardiac Rehabilitation may be covered as part
office for routine care or if the transport services are for
of a health management program value-added service or
a Member’s convenience.
benefit. Phase IV cardiac rehabilitation is excluded.
4. Any Treatment for which there is Insufficient Evidence
11. Care, treatment, services or supplies to the extent the
Of Therapeutic Value for the use for which it is being
Member has obtained benefits under:
prescribed.
5. Any treatment or service related to the provision of a • Applicable law,
non-covered benefit, including educational and • Government program,
administrative services related to the use or • Public or private grant, or
administration of a non-covered benefit, as well as
evaluations and medical complications resulting from • Any plan or program for which there would be no
receiving services that are not covered ("Related charge to the Member in the absence of this Plan
Services"), unless both of the following conditions are However, services obtained in a Veteran’s Home or
met: Hospital for a non-service connected disability, or as
required by the law, are covered. Also covered are care,
• The Related Services are Medically Necessary acute
treatment or services that are otherwise Medically
inpatient care services needed by the Member to treat
Necessary and provided in a Veteran’s Hospital.
complications resulting from the non-covered benefit
when such complications are life threatening at the 12. Chiropractic manipulation of the cervical spine that is
time the Related Services are rendered, as determined long term or maintenance in nature.
by us, and 13. Clinical trial services as follows:
• The Related Services would be a Health Service if the • Cost of Experimental Or Investigational medicines or
non-covered benefit were covered by the Plan. devices that are not exempt from new medicine or
6. Attorney fees. device application by the Food and Drug
7. Behavioral conditions with the following diagnoses: Administration,
• Caffeine-related disorders, • Costs for non-Health Services,
• Communication disorders, • Costs that would not be covered by this Plan for a
non-Experimental Or Investigational treatment,
• Gambling disorders,
• Facility, ancillary, professional services and medicine
• Learning disorders, costs paid for by grants or funding for the trial,
• Mental retardation, • Routine costs that are:
• Motor skills disorders, ♦ Experimental Or Investigational,
• Relational disorders, ♦ Provided solely to satisfy data collection and
• Sexual deviation, or analysis needs and that are not used in the direct
clinical management of the Member, or
• Other conditions that may be a focus of clinical
attention not defined as mental disorders in the most ♦ Services that are clearly inconsistent with widely
recent edition of the American Psychiatric accepted and established standards of care for a
Association's “Diagnostic and Statistical Manual of particular diagnosis, and
Mental Disorders.” • Transportation, lodging, food or other travel expenses
for the Member or any family member or companion
of the Member.
Page 54
14. Complementary or alternative medicine that is not • Dermabrasion or other procedures to plane the skin,
considered standard medical treatment by the traditional including, but not limited to:
United States medical community.
♦ Acne related services such as blue light treatment
Examples of non-standard treatments include, but are of acne, injections to raise acne scars, and removal
not limited to: of acne cysts,
• Acupressure, • Electrolysis,
• Acupuncture, except when acupuncture is provided as • Excision of loose or redundant skin and/or fat after
part of pain management,. the Member has had a substantial weight loss,
• Animal-related therapies, • Facelift surgery or rhytidectomy,
• Ayurveda, • Injection of collagen or other fillers or bulking agents
• Biofeedback, to enhance appearance,
• Bioidentical hormones, • Liposuction,
• Colonic irrigation, • Otoplasty,
• Craniosacral therapy, • Phototherapy or laser therapy for the treatment of
skin conditions, except for the treatment of psoriasis,
• Essential metabolics analysis,
• Reduction mammoplasty (except for any surgery
• Live blood cell analysis, related to breast cancer and as required by the law),
• Massage therapy, • Reversal of inverted nipples,
• Megavitamin therapy, • Scar revision,
• Mind-Body therapies, • Septoplasty, septorhinoplasty, or rhinoplasty,
• Music or artistic therapies, • Skin tag removal,
• Reiki, • Spider vein removal (including, but not limited to
• Reflexology, sclerotherapy),
• Rolfing, and • Tattooing or removal,
• Therapeutic touch. • Thigh, leg, hip, or buttock lift procedures,
15. Concierge services (which means the fees a provider • Treatment of craniofacial disorders, except as
charges as a condition of selecting or using his/her described in the “Craniofacial Disorders” subsection
services). of the “Benefits” section,
16. Cosmetic Treatments and procedures, including but not • Treatment of melasma,
limited to:
• Varicose vein treatment, except when there is a
• Abdominoplasty, partial abdominoplasty, repair of history of ulcers or bleeding from a varicose vein, and
diastasis recti, abdominal liposuction or suction • Vascular birthmark removal.
assisted lipectomy of the abdomen,
17. Custodial Care, convalescent care, domiciliary care, long
• Any medical or Hospital services related to Cosmetic term care or rest home care, except for Custodial Care in
Treatments or procedures, connection with extended day treatment programs as
• Benign nevus or any benign skin lesion removal required by applicable federal or state law. Also care
(except when the nevus or skin lesion causes provided by home health aides that is not patient care of
significant impairment of physical or mechanical a medical or therapeutic nature and care provided by
function), non-licensed professionals.
• Benign seborrhic keratosis,
• Blepharoplasty,
• Body piercing,
• Breast augmentation, (except as described in the
"Reconstructive Surgery" or "Durable Medical
Equipment (DME) Including Prosthetics"
subsections of the "Benefits" section or as otherwise
required by the law),
Page 55
18. Dental services, including, but not limited to the • Duplicate charges,
following:
• Services incurred prior to the effective date of
• Any service, procedure, or treatment modality not coverage,
specifically listed in the “Pediatric Dental Care (Under • Services incurred after cancellation of coverage, or
Age 20)” subsection of the “Benefits” section as a losses of eligibility,
covered Dental Service,
• Services incurred in excess of any Contract Year
• For adults (Members age 20 and over), maximum,
• Dental treatments, medications and supplies that are • Services or supplies that are not Medically Necessary
not Medically Necessary, according to accepted standards of dental practice,
• Experimental Or Investigational procedures, • Services that are incomplete,
• Procedures to alter vertical dimension (bite height • Orthodontic services for persons age 20 and over,
based on the resting jaw position) including but not when orthodontics is a covered Dental Service,
limited to, occlusal (bite) guards and periodontal
splinting appliances (appliances used to splint or • Sealants on teeth other than the first and second
adhere multiple teeth together), and restorations permanent molars, or applications applied more
(filings, crowns, bridges, etc.), frequently than every thirty-six months or a service
provided outside of ages five through fourteen,
• Space maintainers for dependent children age ten and
over, • Services such as trauma which are customarily
provided under medical-surgical coverage,
• Services or supplies rendered or furnished in
connection with any duplicate prosthesis or any other • More than two oral examinations of any type in any
duplicate appliance, consecutive 12-month period,
• Restorations which are not of any dental health • More than two prophylaxes in any consecutive 12-
benefit, but primarily Cosmetic Treatment in nature, month period,
including, but not limited to laminate veneers. • More than one full mouth x-ray series in any period
Payment of the applicable Cost-Share of this Plan’s of 36 consecutive months,
Maximum Allowable Amount for the alternate • Bitewing x-rays or vertical bitewing x-rays in excess of
service, if any, will be made toward such treatment eight films in any consecutive 12-month period,
and the balance of the cost remains the responsibility
of the Member. • Adjustments or repairs to dentures performed within
six months of the installation of the denture,
• Personalized, elaborate, or precision attachment
dentures or bridges, or specialized techniques, • Services or supplies in connection with periodontal
including the use of fixed bridgework, where a splinting (adhering multiple teeth together),
conventional clasp designed removable partial denture • Implants and implantology services, including implant
would restore the arch, bodies, abutments, attachments and implant
Payment of the applicable Cost-Share of this Plan’s supported prosthesis (such as crowns, dentures,
Maximum Allowable Amount for the alternate pontics, or bridgework),
service, if any, will be made toward such treatment • Expenses incurred for the replacement of an existing
and the balance of the cost remains the responsibility denture which is or can be made satisfactory,
of the Member,
• Additional expenses incurred for a temporary denture,
• General anesthesia, except for the following reasons:
• Expenses incurred for the replacement of a denture,
♦ Removal of one or more impacted teeth, crown, or bridge for which benefits were previously
♦ Removal of four or more erupted teeth, paid, if such replacement occurs within five years
from the date of the previous benefit,
♦ Treatment of a physically or mentally impaired
person, • Training in plaque control or oral hygiene, or for
dietary instruction,
♦ Treatment of a child under age 11, and
• Completion of reporting forms,
♦ Treatment of a Member who has a medical
problem, when the attending physician requests in • Charges for missed appointments,
writing that the treating Dentist administer general • Charges for services and supplies which are not
anesthesia. This request must accompany the necessary for treatment of the injury or disease, or are
dental claim form. not recommended and approved by the attending
Dentist, or charges which are not reasonable
Page 56
• Scaling and root planing which is not followed, where 23. Family planning and Infertility services, including but not
indicated, by definitive pocket elimination procedures. limited to:
In the absence of continuing periodontal therapy, • Contraceptive drugs and devices, except to the extent
scaling and root planning will be considered a insurance law requires coverage for these items.
prophylaxis and subject to the limitations of that When they are covered, they are covered under the
procedure, “Prescription Drugs” subsection of the “Benefits”
• Periodontal surgery procedures more than once per section,
quadrant in any period of 36 consecutive months, • Home births (except that complications of home
• More than one periodontal scaling and root planning births are covered),
per quadrant in any consecutive 36 month period, • Infertility services not specifically covered under the
• More than two periodontal maintenance procedures “Infertility Services” or “Prescription Drug”
in any consecutive 12-month period, as well as subsections of the “Benefits” section, including but
periodontal therapy, periodontal maintenance not limited to:
procedures in the absence of benefited ♦ All Infertility services following voluntary
comprehensive, sterilization where no attempt at reversal has been
• Services for any condition covered by workers’ made,
compensation law or by any other similar legislation, ♦ Cryopreservation (freezing) or banking of eggs,
• Services to correct or in conjunction with treatment embryos, or sperm,
of congenital malformations (e.g., congenitally ♦ Medications for sexual dysfunction,
missing teeth, supernumerary teeth, enamel and dental
dysplasia), developmental malformation of teeth, or ♦ Recruitment, selection and screening and any
the restoration of teeth missing prior to the effective other expenses of donors (donors of eggs,
date of coverage, and embryos and sperm),
• Claims submitted more than 11 months (335 days) ♦ Reversal of surgical sterilization, and
following the date of service. ♦ Surrogacy and all charges associated with
19. Diagnostic breast tomosynthesis, except for breast surrogacy such as prescription drugs, fertilization
tomosynthesis screening, as described in the or implantation, and
“Mammogram Screenings” subsection of the “Benefits” • Labor doulas and labor coaches.
section.
24. Genetic analysis and testing, except as described in the
20. Educational services, except for educational services in “Infertility Services” or “Genetic Testing” subsections of
connection with extended day treatment program as the “Benefits” section including, but not limited to:
required by applicable federal or state law and except as
described in the “Autism Services” or “Birth To Three • All other genetic testing services, as well as genetic
Program (Early Intervention Services)” sections: testing panels not endorsed by ACMG, ACOG,
ACSO or NCCN,
• Screening and treatment associated with learning
disabilities, • Genetic testing kits available either direct to the
consumer or via a physician prescription,
• Special education and related services, and
• Genetic testing only for the benefit of another family
• Testing, training, rehabilitation for educational member,
purposes.
• Genetic testing to guide personalized medicine,
21. Extracorporeal shock wave therapy for the treatment of
musculoskeletal conditions. • Pharmacogenetics or Pharmacogenomics,
22. Experimental Or Investigational treatment, except as • Repeat genetic testing, and
described in the “Bypassing The Internal • Whole genome or whole exome genetic testing
Appeal/Grievance Process” subsection of the “Claims 25. Gynecomastia surgery.
Filing, Questions And Complaints, And
Appeal/Grievance Process” section. 26. Health club membership and exercise equipment.
Page 57
27. Home health aide care that is not patient care of a • Pneumatic compression devices for the treatment of
medical or therapeutic nature. lymphedema or the prevention of deep vein
28. Homeopathic and holistic treatments. thrombosis,
29. Hypnosis, biofeedback, and acupuncture, except when • Power mobility devices, such as wheelchairs or
acupuncture is provided as part of pain management. scooters,
30. Medical supplies, equipment or prosthetics that are not • TENS units or other neuromuscular stimulators and
durable or that are not on our list of covered equipment. related supplies, either internal or external, for the
treatment of pain or other medical conditions, and
Examples of excluded equipment including, but not
limited to: • Wigs, hair prosthetics, scalp hair prosthetics or cranial
prosthetics, except as described in the “Benefits”
• Any item not primarily medical in nature section.
• Any item or service which is not covered by the 31. Neuropsychological and neurobehavioral testing, except
Medicare or Medicaid programs to assess the extent of any cognitive or developmental
• Assistive technology and adaptive equipment, delays due to chemotherapy or radiation treatment in a
including but not limited to: child diagnosed with cancer.
♦ Communication boards, computers, equipment or 32. New Treatments for which we have not yet made a
devices, coverage policy, except for drugs with FDA approval for
the use for which they are prescribed.
♦ Gait trainers,
33. Non-licensed professionals.
♦ Prone standers,
34. Non-Medically Necessary services or supplies, except as
♦ Supine boards, and required by applicable federal or state law.
♦ Other equipment not intended for use in the 35. Non-medical supportive counseling services (individual
home, or group) for alcohol or substance abuse (e.g., Alcoholics
• Beds, bedding and bed-related items, Anonymous).
• Bone growth (osteogenic) stimulators (spinal, non- 36. Non-surgical treatment of temporomandibular joint
spinal and ultrasonic), (TMJ) dysfunction or temporomandibular disease (TMD)
syndrome, including but not limited to:
• Clothing or bodywear, except as otherwise covered in
the “Benefits” section, • Appliances,
• Comfort or convenience items, including but not • Behavior modification,
limited to: • Physiotherapy, and
♦ Furniture or modifications to furniture, • Prosthodontic therapy.
♦ Home climate control devices, and 37. Overnight or day camps focused on illness or disability.
♦ Tubs, spas or saunas, 38. Over-the-counter (OTC) items of any kind, including but
• Compression and cold therapy devices, not limited to home testing or other kits and products,
except as provided in the “Benefits” section.
• Compression or anti-embolism stockings,
39. Pain management procedures and services, except as
• Cryotherapy; polar packs, provided in the “Pain Management” subsection of the
• Exercise equipment, “Benefits’ section, as follows:
• Foot orthotics, except if the Member is diabetic, • Automated percutaneous lumbar discectomy
• Hearing aids, except as described in the “Benefits” (APLD)/automated percutaneous nucleotomy,
section, • Coblation Nucleoplasty™, disc nucleoplasty,
• Home or automobile equipment or modifications,. decompression nucleoplasty plasma disc
decompression,
• Items used to perform or assist with personal hygiene,
• Endoscopic anterior spinal surgery/Yeung
• Lifts of any type, endoscopic spinal system (YESS)/percutaneous
• Mechanical stretch devices for treatment of joint endoscopic diskectomy (PELD)/arthoroscopic
stiffness (pre- or post-surgery) or joint contractures, microdiscectomy, selective endoscopic discectomy
(SED),
• Myoelectric or electronic prosthetic devices,
Page 58
• Endoscopic disc decompression, ablation or annular • Certain prescription drugs and supplies are no longer
modulation using the DiscFX™ System, covered when Clinically Equivalent Alternative Drugs
• Endoscopic epidural adhesiolysis, Or Supplies are available unless otherwise required by
law, or are otherwise determined by us to be
• Epiduroscopy, epidural myeloscopy, epidural spinal Medically Necessary. In order for that drug or supply
endoscopy, to be considered Medically Necessary, the provider
• Intradiscal and/or paravertebral oxygen/ozone who wrote the prescription must substantiate to us, in
injections, writing, a statement that includes the reasons why use
of the drug or supply is more medically beneficial
• Intervertebral disc biacuplasty/cooled radiofrequency, than the Clinically Equivalent Alternative Drug Or
• Interdiscal electrothermal annuloplasty/Interdiscal Supply.
electrothermal therapy (IDET), • Compounded prescriptions, unless at least one
• Intralesional Anesthesia or Postoperative Disposable ingredient in the compounded prescription is FDA
Ambulatory Regional Anesthesia, approved and the FDA component(s) of the
• Percutaneous laminotomy/laminectomy, compound is covered.
percutaneous spinal decompression, • Drugs or medications if they include the same active
• Percutaneous laser discectomy/decompression, laser- ingredient or a modified version of an active
assisted disc decompression (LADD), ingredient and they are:
• Percutaneous epidural adhesiolysis, percutaneous ♦ Therapeutically equivalent or therapeutically an
epidural lysis of adhesions, Racz procedure, alternative to a covered prescription drug, or
• Percutaneous intradiscal radiofrequency ♦ Therapeutically equivalent or therapeutically an
thermocoagulation (PIRFT), intradiscal alternative to an over-the-counter (OTC) product.
radiofrequency thermomodulation or percutaneous This exclusion does not apply if the drugs or
radiofrequency thermomodulation, medications are determined to be Medically
Necessary.
• Prolotherapy, and
• Spinal Distraction Systems. • Drugs or preparations, devices and supplies to
enhance strength, physical condition, endurance or
40. Peak flow meters. physical performance, including performance
However, peak flow meters may be covered if: enhancing steroids.
• The Member is enrolled in our asthma health • Drugs that are lost, stolen, or damaged after they are
management program, dispensed by the pharmacy will not be replaced.
• The member is being actively case managed, and • Drugs that may be purchased without a prescription,
including prescription drugs with non-prescription
• The use of the peak flow meter is approved by us.
OTC equivalents, unless the prescription version of
When the above conditions are met, peak flow meters the over the counter equivalent is determined to be
may be provided as part of an asthma health management Medically Necessary or as otherwise described in this
program value-added service or as a benefit. Policy.
41. Prescription drugs or supplies, including, but not limited • Infant formulas, dietary or food supplements,
to: prescription medical foods and nutritional supplies,
• All drugs or medications in a therapeutic drug class if except as described in the "Nutritional Supplements
one of the drugs in that therapeutic drug class is not a And Food Products" and “Prescription Drug”
prescription drug, unless the drugs or medications are subsections of the "Benefits."
Medically Necessary. • Medications for sexual dysfunction.
• Antibacterial soap/detergent, shampoo, • Prescription contraceptive methods used in
toothpaste/gel, or mouthwash/rinse. connection with birth control, if specified on your
• Any treatment, device, drug or supply to increase or Benefit Summary.
decrease height or alter the rate of growth, including
devices to stimulate growth, and growth hormones.
• Appliances or devices, except as otherwise required
by applicable law.
Page 59
• Prescription drugs, medications or supplies: • Smoking cessation products, except as described in
♦ Covered by workers' compensation law or similar your Benefit Summary, or.to treat nicotine addiction.
laws, or covered by workers' compensation For nicotine addiction treatment, the product must be
coverage, even if you choose not to claim those obtained with a prescription and Pre-Authorized.
benefits, subject to applicable state law, In addition, we may also cover smoking cessation
products if:
♦ Dispensed before the Member’s effective date or
after his or her termination date, ♦ The Member is being actively case managed, and
♦ Dispensed in a Hospital or other inpatient facility, ♦ The use of the smoking cessation product is
♦ Dispensed or prescribed in a manner contrary to approved by us.
normal medical practice, When those conditions are met, smoking cessation
products may be provided as part of a health
♦ Furnished by the United States Veterans' management program value-added service or as a
Administration,
benefit.
♦ Not required for the treatment or prevention of
• Vitamins, minerals, hematinics and supplements,
illness or injury,
except prescription pre-natal vitamins or as otherwise
♦ Obtained for the use by another individual, described in this Policy.
♦ Obtained from outside of the United States by any 42. Private room accommodations or private duty nursing in
means, a facility.
♦ Provided in connection with treatment of an 43. Rehabilitative physical therapy, occupational therapy,
occupational injury or occupational illness, subject speech therapy or chiropractic therapy that is long term
to applicable state law, or maintenance in nature.
♦ Refilled in excess of the number the prescription 44. Routine foot care (except when the Member is a
calls for, or refilled after one year from the date of diabetic), including, but not limited to: the evaluation or
the order for the prescription drug, treatment of subluxations (structural misalignments of
the joints) of the feet, and the elevation or treatment of
♦ Re-packaged in unit dose form,
flattened arches and the prescription of supportive
♦ Unless the drug is included on the preferred drug devices.
guide (formulary) or a medical exception is
45. Routine physical exams or immunizations at an Urgent
granted,
Care Center.
♦ Used for or in preparation of Infertility treatment
46. Sensory and auditory integration therapy, unless covered
that is not specifically covered under this Policy,
under the “Autism Services” or “Birth To Three Program
including but not limited to Experimental or
(Early Intervention Services)” subsections of the
Investigational Infertility procedures,
“Benefits” section.
♦ Used for the purpose of weight gain or reduction, 47. Services and supplies exceeding the benefit maximums.
obesity, including but not limited to stimulants,
preparations, foods or diet supplements, dietary 48. Services and supplies not specifically included in this
regimens and supplements, food or food document.
supplements, appetite suppressants and other 49. Services, drugs, medications or supplies obtained outside
medications, of the United States, except for Emergency Services.
♦ Used for travel, 59. Services or supplies rendered by a physician or provider
♦ Used in connection with or for a Cosmetic to himself/herself, or rendered to his/her family
Treatment or hair loss, including but not limited members, such as parents, grandparents, spouse,
to health and beauty aids, chemical peels, children, step-children, grandchildren or siblings.
dermabrasion treatments, bleaching, creams, 51. Services required by or received at a Wilderness Camp or
ointments or other treatments or supplies, to a boarding school, including:
remove tattoos, scars or to alter the appearance or
• Medications, including prophylactic,
texture of the skin, and
• Physical examinations, blood tests,
♦ Not suggested for use by manufacturers or not
approved by the federal FDA or our Pharmacy • Supplies, and
and Therapeutic Committee, unless they are • Vaccinations/immunizations
Medically Necessary.
Page 60
52. Services required by third parties or pursuant to a court • Costs for getting answers to billing, insurance
order, including: coverage or payment question,.
• Blood tests, • Costs for provider to provider discussions,
• Medications, including prophylactic, • Costs for Referrals to providers outside the online
• Physical examinations, care panel,
• Supplies, and • Costs for reporting normal lab or other test results,
• Vaccinations/immunizations. • Costs for requesting office visits,
53. Services obtained for foreign or domestic travel, • Costs for research services by providers not directly
including: responsible for your care,
• Camp, • Costs for services not documented in provider
records,
• Employment,
• Costs from an outside laboratory or shop for services
• Insurance, in connection with an order involving devices (e.g.,
• Licensing, prosthetics, orthotics) which are manufactured by that
laboratory or shop, but which are designed to be
• Pursuant to a court order, and
fitted and adjusted by the attending physician,
• School.
• Fees associated with data usage on a mobile phone or
54. Solid organ transplant and bone marrow transplant fees for short message service (SMS)/text messaging,
transportation costs, including, but not limited to:
• Membership, administrative, or access fees charged by
• Any expenses for anyone other than the transplant physicians or other providers Examples of
recipient and the designated traveling companion, administrative fees include, but are not limited to:
• Any expenses other than the transportation, lodging Fees charged for educational brochures or calling a
and meals described in the “Benefits” section, patient to provide their test results.
• Expenses over those described in the “Benefits” • Provider fees for technical costs or facility fees for the
section, provision of Telemedicine services, and
• Local transportation costs while at the transplant • Telemedicine services involving e-mail, fax, texting, or
facility, and audio-only telephone.
• Rental car costs. 59. Third party coverage, such as other primary insurance,
55. Speech therapy for stuttering, lisp correction, or any workers' compensation and Medicare will not be
speech impediment, except as described in the “Benefits” duplicated.
section. 60. Transportation, accommodation cost, and other non-
56. Sports medicine clinic services and treatments and the medical expenses related to Health Services (whether they
services of a personal trainer. In addition, there is also no are recommended by a physician or not), except as
coverage for any diagnostic services related to any of described in the “Benefits” section.
these programs, services or procedures. 61. Treatment of snoring, including, but not limited to:
57. Surgical procedures using an artificial disc. • Laser-assisted uvulopalatoplasty,
58. Telemedicine consultation services not specifically • Snore guards,
covered under the “Telemedicine Consultation Services”
subsection of the “Benefits” section, including but not • Somnoplasty, and any other snoring-related
limited to: appliances.
62. Ventricular assist devices, except for bridge to heart
• Costs for asking for Pre-Authorizations or Pre- transplantation.
Certifications,
• Costs for diet counseling or prescriptions for Drug
Enforcement Administration (DEA) controlled
substances or lifestyle drugs, such as sexual
dysfunction, diet drugs or hair growth drugs,
• Costs for furnishing and/or receiving medical records
and reports,
Page 61
63. Vision services including, but not limited to: A Member who fails to secure no-fault insurance required by
law shall be deemed to be his or her own insurer and we
• Adult eye glasses and contact lenses,
shall reduce his or her benefits for covered Health Services
• Eye surgeries and procedures primarily for the by the amount of basic reparations benefits or other benefits
purpose of correcting refractive defects of the eyes, provided for injury if such a no-fault policy had been
including, but not limited to: obtained.
♦ Laser surgery, If a Member is entitled to benefits under a no-fault or other
♦ Orthokeratology, and automobile insurance policy, benefits for covered Health
Services will only be provided when a Member follows all of
♦ Radial keratomy, the guidelines stated in the “Managed Care Rules And
• Non-standard prescription lenses, frames, and Guidelines” section. It is necessary to follow all the
prescription contact lenses, including tinted lenses, guidelines in the “Managed Care Rules And Guidelines”
• Vision and hearing examinations (except as described section in order for us to continue to provide benefits for
in the “Eye Care” and “Hearing Screenings” covered Health Services when the no-fault or other
subsections of the “Benefits” section), and automobile insurance policy benefits are exhausted.
• Vision therapy and vision training Workers’ Compensation

64. War related treatment or supplies, whether the war is As required by law, we will not exclude coverage under this
declared or undeclared. Plan for a sole proprietor who is eligible for, but who does
65. Weight loss/control services, equipment and treatment, not elect, workers’ compensation.
including, but not limited to: In addition, to the extent permissible by law, no benefits
• Bariatric surgery, shall be provided for covered Health Services paid, payable
or eligible for coverage under any workers’ compensation
• Commercial diet plans and any clinics and services in law, employer’s liability or occupational disease law, denied
connection with such plans or programs, under a managed workers’ compensation program as Out-of-
• Exercise equipment, and Network services or which, by law, were rendered without
expense to the Member.
• Weight loss or weight control programs.
We shall be entitled to the following:
OTHER INSURANCE, RIGHTS OF
1. To charge the entity obligated under such law for the
RECOVERY, SUBROGATION AND dollar value of those benefits to which the Member is
REIMBURSEMENT entitled.
OTHER INSURANCE 2. To charge the Member for such dollar value, to the
extent that the Member has been paid for the covered
Automobile Insurance Policies Health Services.
To the extent permissible by law, benefits shall not be
3. To reduce any sum owing to the Member by the amount
provided by this Plan for covered Health Services paid,
that the Member has received payment.
payable or required to be provided as basic reparations
benefits under any no-fault or other automobile insurance 4. To place a lien on any sum owing to the Member for the
policy. amount we have paid for covered Health Services
rendered to the Member, in the event that there is a
We shall be entitled: disputed and/or controverted claim between the
• To charge the insurer obligated under such law for Member’s employer and the designated workers’
the dollar value of those benefits to which a Member compensation insurer as to whether or not the Member is
is entitled, entitled to receive workers’ compensation benefits
payments.
• To charge the Member for such dollar value, to the
extent that the Member has received payment from 5. To recover any such sum owing as described above, in
any and all sources, including but not limited to, first the event that the disputed and/or controverted claim is
party payment, and resolved by monetary settlement to the full extent of such
settlement.
• To reduce any sum owing to the Member by the
amount that the Member has received payment from
any and all sources, including but not limited to, first
party payment;
Page 62
6. If a Member is entitled to benefits under workers’ SUBROGATION AND REIMBURSEMENT
compensation, employer’s liability or occupational disease
law, it is necessary to follow all of the guidelines in the You or your covered dependents may receive or be eligible
“Managed Care Rules And Guidelines” section in order to receive Plan Benefits for an injury or an illness for which
for this Plan to continue to provide benefits for covered some third person, organization, or governmental entity is
Health Services when the workers’ compensation benefits liable to pay damages. In these cases, in accordance with
are exhausted. applicable law, the third person, organization or
governmental entity may have primary payment
Rights To Receive And Release Necessary responsibility and not by way of limitation, may include the
Information following sources: a third party tortfeasor or his insurer,
payments under an uninsured or underinsured motorist
We routinely send questionnaires to Members where the
policy, a worker’s compensation award or settlement, a
order of coverage and benefits among responsible plans is in
recovery made pursuant to a no-fault insurance policy, and
question. We reserve the right to deny any or all claims until any medical payment coverage in any automobile or
the completed questionnaire has been returned to us. homeowner’s insurance policy. For claims we paid in relation
Any person claiming services or payments under this Plan to that injury or illness, we or our agent will have a lien upon
must furnish us, or our agents, any information needed to the proceeds of any recovery from that third person,
implement the subrogation provisions. For the purposes of organization or governmental entity. You and your covered
implementing these provisions or a similar provision of any dependents agree to reimburse us, in full, without any offset
other plan, we may, without the consent of or notice to any or reduction under any theory of attorney or common fund,
person, release to or obtain from any entity any information made-whole, or comparative negligence, provided, however,
needed for such purposes to the extent permitted by law. that if health benefits were specifically subtracted from the
proceeds of a judicial award, no reimbursement of that
Facility Of Payment amount of health benefits shall be required. That lien will be
If another plan makes payments for covered Health Services equal to the value of any services provided or paid for under
that we are responsible for, we may pay to that plan any this Plan in relation to that injury or illness. The lien may,
amounts we determine to be warranted in order to satisfy the but need not, be filed with such third person, organization,
intent of this section. Amounts paid will be deemed to be or governmental entity or in any court of competent
services or payments under this Plan. To the extent of those jurisdiction.
payments, we will be fully released from liability under this When permitted by law, we may require the Member, his or
Plan. her guardian, personal representative, estate, dependents or
survivors, as appropriate, to assign his or her claim against
RIGHTS OF RECOVERY the third person, organization, or governmental entity to us
When payments or services have been made or arranged by to the extent of that right or claim. We may further require
us in excess of the maximum for allowable expenses, no those individuals or entities to execute and deliver those
matter to whom paid, we will have the right to recover the instruments and to take such other reasonable actions as may
excess from any persons (including you), insurance be necessary to secure our rights.
companies, or other organizations. Our right to do that will
be limited to the amount that you have received from
another plan.
Page 63
CLAIMS FILING, QUESTIONS AND Bills From A Non-Participating Provider
COMPLAINTS, AND If you or your Eligible Dependents receive care from a Non-
APPEAL/GRIEVANCE PROCESS Participating Provider, a claim must be submitted to us at the
We have the right to review any claims and to interpret and appropriate address listed in the “Important Telephone
apply the terms of this Plan to determine whether benefits Numbers And Addresses” section.
are payable. The claim should include the following information:
CLAIMS FILING • The Subscriber’s name,

Claims must be received by us within 180 days from the date • The patient’s name and ConnectiCare ID number
the services, medications or supplies were received. Claims (including suffix),
submitted more than 180 days after the date the services, • A complete, itemized bill for services, which includes
medications or supplies were received will not be both a description of the service and the diagnosis.
reimbursed.
Charge card receipts and "balance due" statements are
You can find out the status of your medical claims on our not acceptable.
web site at www.connecticare.com.
• If the claim was a result of an Emergency or Urgent
You can find out the status of your behavioral health claims Care you or your Eligible Dependents needed while
(those for mental health and alcohol or substance abuse) on outside of the United States, make sure the itemized
the OptumHealth Behavioral Solutions web site at bill is written or translated in English and that it
www.liveandworkwell.com. shows the amount you paid in U.S. dollars. We
recommend that you include your charge receipt with
Bills From A Participating Provider the itemized bill.
When you receive covered Health Services from a Generally, our payment for covered Health Services
Participating Provider, you are responsible for paying for any provided by a Non-Participating Provider is made directly to
non-covered services and all the Cost-Share amounts of this you, and you are responsible for paying the provider of
Plan, including the Plan Deductible, Copayment amounts, service, unless you write on the claim form that you want us
and any Coinsurance amounts. The Participating Provider to pay the provider, with the following exceptions:
who treated the Member will file a claim with us, and any
payment from us will be made to the billing provider. • We will pay an ambulance company provider directly
when there is a law that permits us to do so.
Special Rules If You Are Enrolled In Our POS
Deductible Open Access Plans Or Our POS Open • We will reimburse the Non-Participating Provider
Access H DH P Plan directly when the covered services are rendered in
An explanation of benefits (EOB) will be sent to you, which Connecticut by the Non-Participating Provider for
will indicate: the diagnosis or treatment of a substance use
disorder, if the provider is otherwise eligible for
• The Participating Provider’s charges, reimbursement under this Plan.
• What charges in what amounts were applied to the We may also pay you directly, if the Non-Participating
Plan Deductible, Provider does not provide us with information that we
• What charges in what amounts were paid by us, request for claim payment.
• The reasons for any adjustments to those billed Payment To Custodial Parent
charges, and In situations where we have not paid your Eligible
• The amount you are required to pay to the Dependent children’s claims directly to the provider, the law
Participating Providers, if any. may require that we send the payment directly to the
Any amount owed to the Participating Providers must be custodial parent if we are notified in writing, even if that
paid directly to the provider. Contact us if the Participating parent is not a participant under this Plan.
Provider bills you for more than the EOB says you must pay.
Claims For Emergency Services
If you have any questions about your claims, you should call Review a claim for payment for Emergency Services
our Members Services Department. provided by Non-Participating Hospitals or other Non-
Participating Providers make sure it is complete before you
send the claim to us. In some cases, emergency room claims
sent to us by a Hospital may be denied, if they have missing,
incomplete or improperly coded information.
Page 64
If You Are Covered By Another Insurance APPEAL/GRIEVANCE PROCESS
Plan If you are not satisfied with a decision we or our Delegated
Programs have made regarding Health Services, benefits,
If you or your Eligible Dependents are covered under
Pre-Authorization, Pre-Certification or claims, then you or
another plan and we are the secondary carrier, you have 180
your authorized representative may request an
days from the date the primary plan processed the claim to
Appeal/Grievance on your behalf.
submit the claim to us. Check the “Other Insurance, Rights
Of Recovery, Subrogation And Reimbursement” section for Of course, before pursuing the Appeal/Grievance
a description of how to determine if this Plan is the primary process, you should consider seeking immediate
or secondary insurance company and any requirements that assistance from our Member Services Department, as
apply to you. described in the “Questions And Complaints”
subsection. Often, questions and complaints can be
Remind your provider when you or your Eligible
resolved quickly and informally by speaking with one of our
Dependents are covered under another plan, so the
representatives. However, if you choose to make use of the
Member’s services can be billed and paid correctly.
Appeal/Grievance process, we will not subject you to any
Refund To Us Of Overpayments sanctions or impose any penalties on you. You may also
contact the Member Services Department to request
Whenever we have made payments for Health Services,
reasonable access to and copies (free of charge) of all
including prescription drugs, either in error or in excess of
documents, records and other information relevant to your
the maximum amount allowed under this Plan, we have the
benefit request.
right to recover these payments from:
The Appeal/Grievance process is divided into two
• Any person to or for whom the payments were made, categories.
• Any insurance companies, and 1. One category deals with the Medical Necessity
• Any other person or organization. Appeal/Grievance of a particular Health Service, such
You have no right to expect future coverage for non-covered as a denial of a request for Pre-Certification of an
services, supplies or medicines, because of payments made inpatient admission or the Pre-Authorization of a certain
by us in error. surgical procedure.
Our right to recover our incorrect payment may include 2. The other category deals with the Administrative (Non-
subtracting amounts from future benefit payments. You, Medical Necessity) Appeal/Grievance, such as a
personally and on behalf of your Eligible Dependents, must decision that interprets the application of Plan rules and
complete and send us any documents we ask for and do that does not relate to Medical Necessity.
whatever is necessary to protect our right to recover any In either case, the Appeal/Grievance request may be initiated
erroneous or excess payments. orally, electronically or by mail by calling, faxing or writing
us. We have designated our Member Services Department
QUESTIONS AND COMPLAINTS to coordinate Appeals/Grievances. Our Member Services
You or your authorized representative can ask questions or Department can be contacted as follows:
send us complaints or Appeals/Grievances about benefits Telephone: 1-800-251-7722
and other issues concerning this Plan. Since most questions
or complaints can be resolved informally, we suggest that Facsimile: 1-800-319-0089 or (860) 674-2866
you contact our Member Services Department first. In ConnectiCare
addition, you may also submit a complaint by using our web Member Services Appeals/Grievances
site at www.connecticare.com. PO Box 4061
Representatives are available Monday through Friday, during Farmington, Connecticut 06034-4061
regular business hours, to explain policies and procedures For all behavioral health Appeals/Grievances, our behavioral
and answer your questions. If you are calling after normal health Delegated Program can be contacted as follows:
business hours, you should leave a detailed voice mail
message, including your ConnectiCare ID number and your Telephone: 1-866-556-8166
telephone number. An associate will return your telephone Facsimile: 1-800-322-9104
call during regular business hours.
OptumHealth Behavioral Solutions
In the event a problem or complaint cannot be informally Attention: Complaints and Appeals Department
resolved, a formal Appeal/Grievance process is available, as 1900 East Golf Road, Suite 200
outlined below. Schaumburg, IL 60173
Page 65
When contacting us or our behavioral health Delegated Medical Necessity Appeal
Program, you should explain why you feel the original
decision should be overturned. You are entitled and Internal Appeal Process
encouraged to submit additional written comments, If you disagree with a decision regarding the Medical
documents, records and letters and treatment notes Necessity of a particular Health Service, such as a denial of
from your health care professional and any other a request for Pre-Certification of an inpatient admission or
material relating to your benefit request for the Pre-Authorization of a certain surgical procedure, you
consideration. You have the right to ask your health may Appeal/Grieve that decision.
care professional for such letters or treatment notes. Our internal Appeal/Grievance process is designed to resolve
Appeals/Grievances quickly and impartially through the use
The Appeal/Grievance must be filed with ConnectiCare of an independent review organization of Clinical Peers
as soon as possible after you receive the original (except for behavioral health reviews, which are reviewed by
decision, but no later than 180 calendar days after the an appropriately licensed Clinical Peer through our
Pre-Authorization request was denied or 180 calendar behavioral health Delegated Program).
days after the claim for benefits was denied, whichever 1. We will investigate your Appeal/Grievance request. If
comes first. If you fail to submit your request within the during this investigation, we acquire new or additional
180 calendar days, you lose your right to an evidence or new or an additional scientific or clinical
Appeal/Grievance. rationale, it will be reviewed as part of your
You may contact the Commissioner of the State of Appeal/Grievance. We will provide such newer
Connecticut Insurance Department, the Division of additional information to you or your representative for
Consumer Affairs within the Insurance Department or the review. You will have five business days to respond to
Office of Healthcare Advocate at any time for assistance, the new or additional information before we send your
complaints or upon the completion of our internal Appeal/Grievance to the independent review
Appeal/Grievance process. Their contact information is as organization.
follows: 2. The independent review organization will arrange to have
State of Connecticut Insurance Department the Appeal/Grievance reviewed by a Clinical Peer who
Insurance Commissioner was not involved in the original decision. If the Clinical
PO Box 816 Peer agrees with our decision to deny coverage, but uses
Hartford, Connecticut 06142-0816 new or additional information for his/her decision, then
860-297-3900 you or your authorized representative will be provided
with the new or additional information and will have five
Or business days to respond to the new or additional
The Consumer Affairs Unit information before the decision is issued.
1-800-203-3447 3. You or your authorized representative and your
Office of the Healthcare Advocate practitioner will be sent a written decision no later than
P.O. Box 1543 30 calendar days for pre-service and concurrent
Hartford, CT. 06144 Appeals/Grievances or 60 calendar days for post service
Appeals/Grievances.
Or
4. If you are not satisfied with the decision, you or your
(Toll Free) 1-866-466-4446 authorized representative or any provider with your
or consent may be able to have the decision reviewed by
www.ct.gov/oha Clinical Peers who have no association with us by
or submitting a request for an external review through the
Email: healthcare.advocate@ct.gov State of Connecticut Insurance Department when the
Adverse Determination or final Adverse Determination
involves an issue of rescission, eligibility, Medical
Necessity, appropriateness, health care setting, level of
care or effectiveness. Please refer to the “External
Review And Expedited External Review” provision in
this subsection.
Page 66
Urgent Care Appeals/Grievances All Other Urgent Requests
You may file an Appeal/Grievance on an urgent basis with A decision on an urgent Appeal/Grievance will be made as
us if: soon as possible, taking into account your condition. If we
receive all of the necessary information with your
• We have issued an Adverse Determination for
Appeal/Grievance, you will receive a decision within two
coverage: business days of receipt of all necessary information but no
♦ And the time period for making a non-urgent care later than 72 hours after we’ve received your
request determination could seriously jeopardize Appeal/Grievance, except as noted below. If we need
your or your covered dependent's life or health or additional information in order to make the decision, then
ability to regain maximum function, or we will contact you within 24 hours of our receipt of your
♦ In the opinion of a health care professional with Appeal/Grievance to tell you specifically what information
knowledge of the medical condition, you or your we need, and you will have 48 hours to provide us with that
covered dependent would be subject to severe information. We will make the decision no later than 24
pain that could not be adequately managed hours after receipt of the missing information or 72 hours
without the Health Services or treatment related from the date/time the Appeal/Grievance was received
to the Appeal/Grievance, when the requested information is not provided to make the
determination.
• Your request concerns a substance use disorder or a
co-occurring mental disorder, or If the urgent Appeal/Grievance involves an Adverse
Determination of a concurrent review Urgent Care request,
• Your request concerns a mental disorder requiring the treatment shall be continued without liability to you until
inpatient services, Partial Hospitalization, residential you have been notified of the review decision.
treatment, or Intensive Outpatient Services necessary
to keep you from requiring an inpatient setting. If you are not satisfied with the urgent Appeal/Grievance
decision made by us, then you, your authorized
Behavioral Health Urgent Requests representative or any provider with your consent may request
A decision on an urgent Appeal/Grievance concerning a an external review through the State of Connecticut
substance use disorder, a co-occurring mental disorder or a Insurance Department when the Adverse Determination or
mental disorder requiring inpatient services, Partial final Adverse Determination involves an issue of Medical
Hospitalization, residential treatment or intensive outpatient Necessity, appropriateness, health care setting, level of care
services necessary to keep you from requiring an inpatient or effectiveness. Please refer to the "External Review And
setting will be made as soon as possible, taking into account Expedited External Review" provision in this subsection.
your condition, but not later than 24 hours after receipt of
the request, provided that we have the information Bypassing The Internal Appeal/Grievance Process
necessary to make a determination and provided if the If any of the following circumstances apply, you may be able
Urgent Care request is a concurrent review request to extend to bypass our internal Appeal/Grievance process and file a
a course of treatment beyond the initial period of time or the request for an expedited external review:
number of treatments, such request is made at least 24 hours
• You have a medical condition for which the time
prior to the expiration of the prescribed period of time or
period for completion of an expedited internal
number of treatments. For reviews of an Appeal/Grievance
Appeal/Grievance would seriously jeopardize your
involving a concurrent review request, your treatment shall
life or health or would jeopardize your ability to
be continued without liability to you until you have been
regain maximum function, or
notified of the review decision.
• The Adverse Determination involves a denial of
coverage based on a determination that the
recommended or the requested Health Service or
treatment is Experimental Or Investigational and your
treating health care professional certifies in writing
that such recommended or requested Health Service
or treatment would be significantly less effective if
not promptly initiated,
Page 67
You, or your provider acting on your behalf with your 3. When filing a request for an external review you will be
consent, may simultaneously file a request for an internal required to authorize the release of any medical records
Appeal/Grievance and an expedited external review. The that may be required to be reviewed for the purpose of
independent review organization will determine whether you making a decision on such request.
will be required to complete the internal Appeal/Grievance 4. The review will require a fee of $25 payable to the State
process prior to conducting the expedited external review. of Connecticut Insurance Department. There is a
Please refer to the “External Review And Expedited maximum fee of $75 per Member per year. This fee may
External Review” provision in this subsection for details on be waived if you are poor or unable to pay by the State of
filing for an expedited external review. Connecticut Insurance Commissioner. The fee is
refunded if the Adverse Determination is reversed or
External Review And Expedited External Review revised.
You or your authorized representative may file a request for 5. If you request an external review or an expedited external
an expedited external review if: review, you will receive additional information including
• You have a medical condition for which the time instructions on how to supply additional comments or
period for completion of an external review would materials related to your benefit request.
seriously jeopardize your life or health or would 6. You or your authorized representative will be provided
jeopardize your ability to regain maximum function, with a written decision from the Independent Review
or Organization (IRO) within 45 calendar days for a
• The final Adverse Determination concerns an standard external review, 20 calendar days for an external
admission, availability of care, continued stay or review involving a health care service or treatment that is
Health Service for which you received Emergency Experimental Or Investigational, 72 hours for an
Services but you have not been discharged from a expedited external review or five calendar days for an
facility, or expedited external review involving a health care service
or treatment that is Experimental Or Investigational,
• The denial of coverage was based on a determination from the IRO's receipt of the request. A decision on an
that the recommended or requested Health Service or expedited review concerning a substance use disorder, a
treatment is Experimental Or Investigational and your co-occurring mental disorder or a mental disorder
treating health care professional certifies in writing requiring inpatient services, Partial Hospitalization,
that such recommended or requested Health Service residential treatment or Intensive Outpatient Services
or treatment would be significantly less effective if necessary to keep you from requiring an inpatient setting
not promptly initiated. will be made as soon as possible, taking into account your
Note: An expedited external review is not available condition, but not later than 24 hours from the IRO's
when the requested services have already been receipt of the request.
provided.
1. The external review or expedited external review request
Administrative (Non-Medical Necessity)
must be submitted to the State of Connecticut Insurance Appeal/Grievance
Department in writing. The address and telephone If you disagree with an Administrative (Non-Medical
number is as follows: Necessity) decision, such as a decision that interprets the
application of Plan rules and that does not relate to Medical
State of Connecticut Insurance Department
Necessity, you may Appeal/Grieve that decision.
Insurance Commissioner
PO Box 816 1. If you file an Appeal/Grievance, we will notify you not
Hartford, Connecticut 06142-0816 later than three business days after we receive your
Appeal/Grievance that you or your authorized
1-860-297-3910
representative are/is entitled to submit written materials
2. The external review request must be made within 120 to us to be considered when conducting a review of your
calendar days of your receipt of the final denial letter. Appeal/Grievance.
However, an expedited external review may be filed
2. When the Appeal/Grievance is received, it will be
without receipt of our final denial letter. You do not need
forwarded for review.
a final denial letter in order to file for an external review
if we fail to strictly adhere to the requirements under the 3. A staff member who was not involved in the original
law with respect to making utilization review and benefit decision will review the Appeal/Grievance.
determinations.
Page 68
4. You or your authorized representative will be provided TERMINATION OF COVERAGE FOR OTHER
with a written decision no later than 20 business days REASONS
after we receive your Appeal/Grievance request. If we
are unable to comply with this time period due to Termination of coverage may occur for other reasons
circumstances beyond our control, the time period may besides the Member’s request.
be extended by us for up to ten business days, provided When termination occurs for any of the reasons that follow,
that on or before the 20th business day we provide you or we will provide the Member with notice that includes the
your authorized representative written notice of the reason why coverage was ended. That notice will be sent to
extension and reason for the delay. the Member as least 30 days before the last day of coverage.
In addition, we will also notify the Exchange of the
TERMINATION AND AMENDMENT termination effective date and the reason for the termination.
This Plan will terminate and your coverage under this Plan
We will make reasonable accommodations for all Qualified
will terminate as follows.
Individuals with disabilities, as required by federal law, before
WHEN A MEMBER TERMINATES COVERAGE we terminate his/her coverage.
The Exchange will permit a Member to terminate coverage Termination of a Member’s coverage occurs in the following
under this Plan, as long as the Member provides the circumstances:
Exchange or us with notice. 1. The Member is no longer eligible for coverage in this
Plan, including the Member moving outside of the State
Effective Dates Of Termination of Connecticut.
1. When a Member’s coverage terminates under this Plan at
Coverage will end on the last day of the month
his/her request, the last day of coverage is as follows:
following the month in which the Exchange notifies
• The termination date requested by the Member, as us (unless the Member requests an earlier
long as the Member provides notice of at least 14 termination date with appropriate notice).
days to us in writing, 2. Non-payment of Premium, and
• If the Member has not given reasonable notices of at
• The three month grace period required for Members
least 14 days, the termination date will be 14 days
receiving Advance Payments Of The Premium Tax
after the Member provides notice,
Credit has been exhausted, or
• On a date determined by us, if we are able to
• The standard one month grace period has been
terminate in less than 14 days and the Member
exhausted.
requests an earlier termination date, or
Coverage will end the last day of the first month of
• The day before coverage begins when the Member is the three month grace period, if termination is
newly eligible for Medicaid, the Children’s Health because the three month grace period has been
Insurance Program or a Basic Health Plan. exhausted.
2. If you are not receiving Advance Payments Of The
Coverage will end on the last day of the standard
Premium Tax Credit, you may initiate termination of
grace period, if termination is because the standard
coverage effective on the last day of the month you
grace period has been exhausted.
notify us in writing. Notification to terminate coverage
must be provided to us prior to the last day of the month 3. The Member’s coverage is rescinded.
in which you request termination of coverage. 4. We no longer participate as a Qualified Health Plan
However, we will permit you to terminate coverage Issuer (QHP Issuer).
retroactive to the end of the previous month, as long as 5. The Member switches from this Plan to another QHP
you let us know before the end of the month after you during an open enrollment period or special enrollment
request to terminate coverage. period.
For example, if you notify us that you wish to terminate Coverage will end the day before the Member
coverage on or before March 30th, we will allow you to becomes effective in the new QHP.
terminate your coverage retroactive to February 28th.
However, if you notify us on March 31st for termination
of coverage on February 28th, we will not accept your
request and termination will be processed for March 31st
and Premium will be due and collected for the month of
March.
Page 69
6. Your death. PREMIUM PAYMENT
Coverage will end the day following your death. We determine the amount, time and manner of the payment
When you die, your surviving spouse, if covered under of Premium. Our determination is subject to approval by the
this Plan, will become the Subscriber. If your surviving Connecticut Insurance Department and the Exchange.
spouse was not covered under this Plan, your Eligible 1. All Premiums must be sent to us in accordance with our
Dependents will continue to be covered provided payment instructions, and according to the rates in force
Premium payments are made on time and they remain on behalf of the number of Members covered under this
eligible for coverage as described in the “Eligibility And Plan, even if Premium is being made in the aggregate for
Enrollment” section. Members of a tribe, tribal organization, or urban tribal
7. In the event a Member has committed fraud (as organization.
determined by a court of competent jurisdiction), or has 2. All Premiums are due and payable on the first day of the
willfully concealed or misrepresented any material fact or month for which coverage applies and the first day of
circumstance in applying for enrollment or in obtaining each calendar month after that. If a grace period is
Plan Benefits. allowed, it means that if payment is not made on or
Coverage will end, as we determine. before the date it is due, it may be paid during the grace
However, we may not contest the Member’s coverage period. Please refer to the “Grace Periods” subsection
under this subsection beyond two years from the below.
Member’s Effective Date of coverage under this Policy. 3. Our bills take into account the membership changes we
8. Upon a Member’s commission of acts of physical or have been notified of and that we have processed.
verbal abuse (which are unrelated to his or her physical or Premium payment must be sent as billed. Membership
mental condition), which pose a threat to or create an changes received and processed afterward will be
intimidating, hostile or offensive working environment reflected on the next bill.
for: 4. The amount, time and manner of payment of Premium
shall be determined by us and shall be subject to the
• Providers,
approval of the State of Connecticut Insurance
• Other Members, or Department and the Exchange.
• Our employees, our affiliates or our subcontractors. In the event of any increase change in Premium, the
Coverage will end, as we determine. Subscriber will be given notice at least 30 days prior to
such change. Payment of the Premium by the Subscriber
9. For a Member’s persistent refusal to comply with
shall serve as the Subscriber’s acceptance of the Premium
treatment that is prescribed and Medically Necessary.
change.
Coverage will end, as we determine.
5. You must notify us at least 14 days prior to the date on
10. For a Member’s failure to take such reasonable actions as which a Member’s coverage is to terminate under this
may be necessary to secure our rights under this Plan. Plan in order for termination to be effective on that date.
Coverage will end, as we determine. This notification must be sent to us in writing.
11. In the event the Member has repeatedly failed to make 6. You must tell the Exchange and us when your address
the required Cost-Sharing payments to providers. changes right away. We will process any appropriate
changes in Premium that may result of that change and
Coverage will end, as we determine. that change in Premium will be effective the day you
AMENDMENT move. You are responsible for any increase in Premium
because of an address change from the date you change
Any amendment to this Policy which reduces or eliminates your address, even if you do not tell us about the change
benefits or coverage or which increases benefits or coverage
until after you move.
with a corresponding increase in Premium is subject to your
approval, except if the increase benefit or coverage is GRACE PERIODS
required by law. If you do not pay the full amount of the Premium by the
Premium due date, a grace period is triggered. A grace period
is an additional period of time during which coverage
remains in effect. If you do not pay the required premium by
the end of the grace period, your Policy is cancelled.
We will provide you with notice when the Premium is past
due.
Page 70
Standard Grace Period 3. We contract with Participating Providers to make sure
This Policy has a standard grace period of one month. This that you will not be billed for any Health Services that are
means if you do not make payment during the standard grace covered by this Plan. You are responsible for services
period, this Policy will terminate on the last day of the grace billed that are subject to subrogation and coordination of
period. You will be liable to us for the payment due benefits and all of the copayments, deductibles and
including those for the grace period. coinsurance you are required to pay if you or your
Eligible Dependents are covered by another plan and that
Payment must reach us in time for us to complete our other plan is determined to be the primary plan. In this
posting process in order for it to be considered paid by the case, a Participating Provider may bill you for
end of the grace period. copayments, deductibles and coinsurance due under that
If Premium is not paid as described above, coverage under other plan (the primary plan). Check the “Other
this Plan will end. Insurance, Rights Of Recovery, Subrogation And
Reimbursement” section to find out your responsibilities.
Advance Payment Of The Premium Tax 4. By being covered under this Plan, you and your Eligible
Credit (APTC) Grace Period Dependents accept all of the rules of this Plan.
1. If a Member is receiving Advance Payment Of The 5. We, upon receipt of a notice of claim, shall furnish to the
Premium Tax Credit (APTC) and has previously paid at Member such forms as are usually furnished by it for
least one month’s Premium, we will provide a grace filing proofs of loss. If such forms are not furnished
period of at least three consecutive months. within 15 days after the giving of such notice, the
2. During this grace period: Member shall be deemed to have complied with the
requirements of this Policy as to proof of loss, upon
• We will pay all incurred claims during the first month submitting, within the time fixed in this Policy for filing
of this grace period, and proofs of loss, written proof covering the occurrence, the
• Any claims that were incurred in the second and third character and the extent of the loss for which claim is
months may be pended, subject to our right to cancel made.
your Policy. 6. No legal action may be taken to recover benefits within
When this occurs, we will notify providers that claims 60 days after notice of claim has been given as specified
may be denied. above, nor may any action be brought after three years
The application of this grace period to claims is based on from the date covered Health Services are received. No
the date of service and not on the date the claim was liability shall be imposed upon us other than for benefits
submitted. provided herein.
7. We will have no liability for benefits other than as
• We will notify the United States Department of
provided by this Plan.
Health and Human Services of the non-payment of
Premium, and 8. The benefits of this Policy are not transferable and may
not be assigned to any third party, except when the
• We will apply any payment received to the first billing
Member indicates on the claim form that payment should
cycle in which payment was delinquent.
be sent directly to the provider of the covered Health
GENERAL PROVISIONS Service or when an ambulance company provider or
1. You agree to cooperate with us and to follow our rules when an out-of-network health care provider for the
and instructions in all administrative matters required for diagnosis or treatment of a substance use disorder is
the administration of this Plan. entitled to be paid directly according to the law.
2. You must meet the eligibility requirements of the 9. We may establish reasonable policies, procedures, rules
Exchange. It is your responsibility to notify the Exchange and interpretations to promote the orderly and efficient
and us within 31 days if you change your residence. administration of this Plan.
If you move within the Exchange Service Area of this 10. If ended for any reason, other than termination for non-
Plan, Premium rates will be adjusted, if necessary, to payment of Premium, this Policy may be reinstated if we
adjust to your new address and the current ages of your received your request for reinstatement within 10 days of
Eligible Dependents, effective at the beginning of the the termination date and all outstanding Premiums are
Premium Period following the change of residence. paid in full.
Page 71
11. This document, including the Exchange enrollment form, 20. This Plan calculates benefits on a Contract Year basis.
Benefit Summary, Riders and supplemental inserts is the This means that benefit changes to your benefit plan
entire contract and understanding between you and us. It become effective upon the Renewal Date (when a new
replaces all prior agreements and understandings relating Policy or amendatory Rider may be issued to you).
to the subject matter. Except as described in this 21. If you receive a Surprise Bill, we may not impose a Cost-
document, this document may be changed, waived, Share or other out-of-pocket expense that is greater than
discharged or ended only when done in writing and the Cost-Share or other out-of-pocket expense that
signed by the party against which enforcement of the would be imposed if those services were rendered by a
change, waiver, discharge or termination is sought. Participating Provider.
12. If any portion of this document is or becomes, for any
reason, invalid or unenforceable, that portion will be DEFINITIONS
ineffective only to the extent of the invalidity or The following defined terms have special meaning and may
unenforceability and the remaining portion or portions be found throughout this document. They are referenced
will nevertheless be valid, enforceable and of full force using capital letters like this (Upper Case).
and effect. ADVANCE PAYMENTS OF THE PREMIUM TAX
13. This Plan will be administered according to the laws of CREDIT (APTC)
the State of Connecticut and the rules, regulations or Payment of the tax credits which are provided on an advance
other standards set forth by the Exchange and/or the. basis to an eligible individual enrolled in a Qualified Health
State of Connecticut Insurance Department. Plan (QHP) through an Exchange.
14. Participating Providers are not our employees or agents. ADVERSE DETERMINATION
They are independent contractors with the responsibility The denial, reduction, termination or failure to provide or
for determining and providing health care for their make payment, in whole or in part, for a benefit under this
patients. Plan requested by a Member or a Member’s treating health
15. A Participating Provider may refuse to provide services care professional, based on a determination by us or our
or treatment to you or your Eligible Dependents if you Delegated Program:
do not pay the required Cost-Share amounts required
under this Plan. • That, based upon the information provided,
16. We are not responsible for your decision to receive ♦ Upon application of any utilization review
treatment, services or supplies provided by Participating technique, such benefit does not meet our
Providers, nor are we responsible or liable for the requirements for Medical Necessity,
treatment, services or supplies provided by Participating appropriateness, health care setting, level of care
Providers. or effectiveness, or
17. This Plan does not limit coverage for conditions just ♦ Is determined to be Experimental Or
because you had the condition before you became Investigational.
covered under the Plan. • Of a Member’s eligibility to participate in this Plan, or
18. This Policy shall be incontestable, except for nonpayment Any prospective review, concurrent review or retrospective
of premium, after it has been in force for two years from review determination that denies, reduces or terminates or
its date of issue. fails to provide or make payment, in whole or in part, for a
19. We will not be liable under this Policy unless proper benefit under this Plan requested by a Member or a
notice is furnished to us that covered Health Services Member’s treating health care professional.
have been rendered to a Member. Written notice must be An Adverse Determination includes a rescission of coverage
given within 60 days after completion of the covered determination for Appeal/Grievance purposes.
Health Services. The notice must include the data
AMBULATORY SURGERY CENTER
necessary for us to determine benefits. An expense will
be considered incurred on the date the service or supply An entity that operates exclusively for the purpose of
was received. furnishing outpatient surgical services to patients not
requiring Hospitalization and whose expected stay in the
Failure to give us notice within the time specified will not center does not exceed 24 hours. It is further defined as a
reduce any benefit if it is shown to our satisfaction that facility that is not owned by a Hospital and which bills for its
the notice was given as soon as reasonably possible, but services under its own unique tax identification number.
in no event will we be required to accept notice more
than two years after covered Health Services are received.
Page 72
AMERICAN INDIAN BENEFIT REDUCTION
An individual who is a member of a Federally Recognized A Benefit Reduction is a reduction in benefits, which applies
Indian tribe. A tribe is defined as any Indian tribe, band, when a Member fails to obtain the Pre-Authorization or Pre-
nation, or other organized group or community, including Certification for certain Medically Necessary health care
any Alaska native village or regional or village corporation services that require Pre-Authorization or Pre-Certification
which is recognized as eligible for the special programs and prior to the receipt of these services from or arranged by a
services provided by the United States because of their status Non-Participating Provider.
as Indians.
BENEFIT SUMMARY
APPEAL/GRIEVANCE (GRIEVE) The document that summarizes the benefits provided under
A written complaint or, if the complaint involves an urgent this Plan and that lists the Copayments, Deductibles and
care request, an oral complaint, submitted by or on behalf of Coinsurance levels that you are required to pay for Health
a Member regarding: Services as well as benefit and Out-Of-Pocket Maximums.
• The availability, delivery or quality of Health Services, BRAND NAME DRUG OR SUPPLY
including a complaint regarding an Adverse A drug or supply manufactured and approved by federal
Determination made pursuant to utilization review, FDA standards that has a proprietary trade name selected by
• Claims payment, handling or reimbursement for the manufacturer used to describe and identify it.
Health Services, or CASE MANAGEMENT
• Any matter pertaining to the contractual relationship The process for identifying Members with specific health
between the Member and us. care needs in order to help in the development and
implementation of a plan that efficiently uses health care
AUTISM SPECTRUM DISORDER (ASD) resources to help the Member manage his/her health.
The autism spectrum disorder as set forth in the most recent
edition of the American Psychiatric Association’s CASE MANAGER
“Diagnostic and Statistical Manual of Mental Disorders.” An individual, usually a registered nurse, who is responsible
for developing and implementing a plan of care that takes
BEHAVIORAL HEALTH PROGRAM into account benefit structure, accepted industry and internal
A Delegated Program under which we may provide for standards, and cost effectiveness in order to help the
management, administration and a network of providers for Member mange his/her health.
mental health, and alcohol and substance abuse services,
under this Plan. In some instances the Behavioral Health CLINICALLY EQUIVALENT ALTERNATIVE
Program may be managed and administered by a Delegated DRUG OR SUPPLY
Program under contract with us. In that event, when this A drug or supply in the same category as an excluded drug or
document refers to determinations, Pre-Authorizations or supply, and determined by us to be an effective alternative.
Pre-Certifications, and other decisions made under the terms CLINICAL PEER
of the Behavioral Health Program, such determinations, Pre- A physician or other health care professional who:
Authorizations or Pre-Certifications, and other decisions are
made by the Delegated Program on behalf of us. • Holds a non-restricted license in a state of the United
States and in the same or similar specialty as typically
BEHAVIORAL THERAPY
manages the medical condition, procedure or
Any interactive Behavioral Therapy derived from evidence-
treatment under review, and
based research and consistent with the services and
interventions designated by the Commissioner of Social • For a review concerning a child or adolescent
Services pursuant to subsection (1) of section 17a-215c, as substance use disorder or mental disorder, holds a
amended, including but not limited to “Applied Behavioral national board certification in child and adolescent
Analysis”, cognitive behavioral therapy, or other therapies psychiatry, or a doctoral level psychology degree with
supported by empirical evidence of the effective treatment of training and clinical experience in the treatment of
individuals diagnosed with ASD. child and adolescent substance use disorder or mental
disorder as applicable, or for a review concerning an
“Applied Behavioral Analysis” means the design, adult substance use or mental disorder, holds a
implementation and evaluation of environmental national board certification in psychiatry or doctoral
modifications, using behavioral stimuli and consequences, level psychology degree with training and clinical
including the use of direct observation, measurement and experience in the treatment of adult substance use or
functional analysis of the relationship between environment mental disorders as applicable.
and behavior, to produce socially significant improvement in
human behavior. Supervision requires at least one hour of
face-to-face supervision of the ASD services provider for
each ten hours of Behavioral Therapy.
Page 73
COINSURANCE COST-SHARE MAXIMUM
Coinsurance means the percentage of the Maximum Generally, the Member’s maximum payment liability per year
Allowable Amount that you are legally responsible to pay for Copayment and Coinsurance as listed in the Benefit
after any applicable Deductible is met. Summary. Check the “Managed Care Rules And Guidelines”
section for more information about how the Cost-Share
When Coinsurance applies as a result of the In-Network
Maximum applies to your Plan.
Level Of Benefits, except as otherwise required by law, the
Coinsurance amount will be calculated based on the lesser of: CUSTODIAL CARE
Those services and supplies furnished to a Member who has
• The physician’s or provider’s charge for the Health
a medical condition that is chronic or non-acute in nature
Service at the time it is provided, or
which either:
• The contracted rate with the physician or provider for
the Health Service. 1. Are furnished primarily to assist the patient in
maintaining activities of daily living, whether or not the
When Coinsurance applies as a result of the Out-Of- Member is disabled, including, but not limited to,
Network Level Of Benefits, except as otherwise required by bathing, dressing, walking, eating, toileting and
law, the Coinsurance amount will be calculated based on the maintaining personal hygiene, or
Maximum Allowable Amount.
2. Can be provided safely by persons who are not medically
A charge by a physician or provider for a Health Service skilled, with a reasonable amount of instruction,
eligible for the Out-Of-Network Level Of Benefits that is in including, but not limited to, supervision in taking
excess of the Maximum Allowable Amount is not considered medication, homemaking, supervision of the patient who
Coinsurance and shall be the Member’s financial is unsafe to be left alone and maintenance of bladder
responsibility. catheters, tracheotomies, colostomies/ileostomies and
COINSURANCE MAXIMUM intravenous infusions (such as TPN) and oral or nasal
Generally, the Member’s maximum payment liability per year suctioning.
for Coinsurance for Health Services covered at the In- These services and supplies are considered custodial and are
Network Level Of Benefits or separately at the Out-Of- not reimbursed or paid, no matter who performs them, even
Network Level Of Benefits, as listed in the Member’s Benefit if you do not have a family member, friend or other person
Summary. Check the “Managed Care Rules And Guidelines” to perform them. If skilled home health care services have
section for more information about how the Coinsurance been Pre-Authorized, the covered Health Services may,
Maximum applies to your Plan. under some circumstances, include custodial services, if
CONNECTICARE, WE, US OR OUR provided by a home health aide in direct support of the
approved skilled home health care.
ConnectiCare Benefits, Inc., the company insuring this Plan.
DEDUCTIBLE
CONTRACT YEAR
The total amount that you must pay during the year toward
January 1st through December 31st.
certain benefits under this Plan before we will begin paying
COPAYMENT MAXIMUM for those benefits. Check your Benefit Summary to see if
Generally, the Member’s maximum payment liability per year benefits for your Plan are covered per calendar year or per
for Copayments for Health Services covered at the In- Contract Year and which benefits are subject to a
Network Level Of Benefits as listed in the Member’s Benefit Deductible.
Summary. Check the “Managed Care Rules And Guidelines” Benefit Deductibles: This Plan may have specific
section for more information about how the Copayment Benefit Deductibles that apply separately to certain
Maximum applies to your Plan. services. The specific Benefit Deductibles must be met by
COPAYMENTS the Member each year before we will begin paying for
One flat fee you pay per day per provider (or provider those benefits. Anything paid by a Member for those
group) for certain Plan Benefits under this Plan. benefits does not count towards meeting the Plan
Deductible (if this Plan has one). Check your Benefit
COSMETIC TREATMENTS Summary to see the Benefit Deductibles that may apply
Any dental, medical or surgical treatment for which the to this Plan.
primary purpose is to change appearance as we determine.
COST-SHARE
The amount of allowed charges which the Member is
required to pay for covered Health Services. Cost-Shares can
be Deductibles, Copayments and/or Coinsurance amounts.
Page 74
Plan Deductible: Some Plan options require you to pay DENTISTRY (DENTAL CARE)
a Plan Deductible. A Plan Deductible is a specific Dentistry (Dental Care) means:
amount each Member must pay in any year towards
certain covered Health Services before we will begin • The diagnosis and treatment of diseases or lesions of
paying our portion of those benefits. After the Plan the mouth and surrounding and associated structures,
Deductible is met, benefits will be paid subject to the • Replacement of lost teeth by artificial ones,
Member’s payment of either a Copayment amount or a
• The diagnosis or correction of malposition of the
Coinsurance amount. Check your Benefit Summary to
teeth, or
see if a Plan Deductible applies to you.
• The furnishing, supplying, constructing, reproducing
DELEGATED PROGRAM
or repairing any prosthetic denture, bridge appliance
An outside company that we may use to manage and or of any other structure to be worn in the mouth; or
administer certain categories of benefits or services provided the placement or adjustment of such appliance or
under this Plan. structure in the human mouth.
When this document refers to determinations, Pre- DRUG THERAPY
Authorizations or other decisions made under the terms of A product administered by a health care professional for use
that Delegated Program, such determinations, Pre- in the diagnosis, cure, treatment, or prevention of disease.
Authorizations, or other decisions are made by the outside
company on our behalf. EFFECTIVE DATE
The date that coverage under this Policy became effective.
DENTAL SERVICES The Effective Date is subject to the payment of Premium
Those diagnostic and therapeutic, medical, surgical services and our receipt and approval of a completed Exchange
and supplies that are Medically Necessary and available to enrollment form.
you and your covered dependents under this Plan. Dental
Services must be provided or rendered by a licensed Dentist, ELIGIBLE DEPENDENTS
dental hygienist, or dental assistant within the scope of his or Persons, other than you (the Subscriber), who are eligible to
her license or authorization in accordance with the laws and be enrolled as Members under this Policy and as described in
regulations of the governmental authority having jurisdiction. the “Eligibility And Enrollment” section of this Policy.
DENTIST EMERGENCY
Dentist means any licensed Dentist (D.D.S., D.M.D.) who is The sudden and unexpected onset of an illness or injury with
actively engaged in the practice of Dentistry, including the severe symptoms whereby a Prudent Layperson, acting
following: reasonably, would believe that emergency medical treatment
is needed.
Endodontist:: A Dentist whose practice is limited to
treating disease and injuries of the pulp and associated An Emergency related to mental health care exists when a
periradicular conditions. Member is at risk of suffering serious physical impairment or
death; or of becoming a threat to himself/herself or others;
Oral and Maxillofacial Surgeon: A dental specialist
or of significantly decreasing his/her functional capability if
whose practice is limited to the diagnosis, surgical and
treatment is withheld for greater than 24 hours.
adjunctive treatment of diseases, injuries, deformities,
defects and esthetic aspects of the oral and maxillofacial The presenting symptoms of the patient, as coded by the
regions. provider on the appropriate claim form or the final
Orthodontist: A dental specialist whose practice is diagnosis, whichever reasonably indicates an emergency
limited to the interception and treatment of malocclusion medical condition, shall be the basis for determining whether
of the teeth and surrounding structures. such services are for an Emergency.
Periodontist: A Dentist whose practice is limited to the EMERGENCY SERVICES

treatment of diseases of the supporting and surrounding Evaluation of an emergency medical condition and treatment
tissues of the teeth. to keep the condition from getting worse.
Prosthodontist: A Dentist whose practice is limited to EXCHANGE (ACCESS HEALTH CT)
the restoration of the natural teeth and/or the The Connecticut Health Insurance Exchange (access health
replacement of missing teeth with artificial substitutes. CT) was established as a quasi-public agency to satisfy the
requirements of the federal Affordable Care Act. The
Exchange is a marketplace where eligible individuals and
small groups will be able to shop for and purchase health
insurance coverage, beginning in October 2014.
Page 75
EXPERIMENTAL OR INVESTIGATIONAL HOME HEALTH AGENCY
A service, supply, device, procedure or medication A duly licensed agency where:
(collectively called "Treatment") will be considered
1. Nursing care is provided by a registered nurse or licensed
Experimental Or Investigational if any of the following
practical nurse,
conditions are present:
2. Home health aide services consisting of patient care of a
1. The prescribed Treatment is available to you or your medical or therapeutic nature are provided by someone
Eligible Dependents only through participation in a other than a registered or licensed practical nurse,
program designated as a clinical trial, whether a federal
Food and Drug Administration (FDA) Phase I or Phase 3. Physical, occupational or speech therapy is provided,
II clinical trial, or an FDA Phase III experimental 4. Certain medical supplies, drugs and medicines prescribed
research clinical trial or a corresponding trial sponsored by a physician and laboratory services to the extent such
by the National Cancer Institute, or another type of services would be covered if Medically Necessary, as we
clinical trial, or determine, are provided, and
2. A written informed consent form or protocols for the 5. Medical social services are provided by a qualified
Treatment disclosing the experimental or investigational Masters-prepared social worker to or for the benefit of a
nature of the Treatment being studied has been reviewed terminally ill Member (i.e., having a life expectancy of six
and/or has been approved or is required by the treating months or less).
facility's Institutional Review Board, or other body
HOSPICE
serving a similar function or if federal law requires such
An agency that provides counseling and incidental medical
review and approval, or
services for a terminally ill (i.e., having a life expectancy of
3. The prescribed Treatment is subject to FDA approval six months or less) individual. To be a Hospice, the agency
and has not received FDA approval for any diagnosis or must:
condition.
1. Be licensed in accordance with all laws,
If a Treatment has multiple features and one or more of its
essential features is Experimental Or Investigational based 2. Provide 24-hour-a-day, seven days-a-week service,
on the above criteria, then the Treatment as a whole will be 3. Be under the direction of a duly qualified physician,
considered to be Experimental Or Investigational and not 4. Have a nurse coordinator who is a registered graduate
covered. nurse with clinical experience, including experience in
GENERIC DRUG OR SUPPLY (GENERICS) caring for terminally ill patients,
A drug or supply manufactured and approved by federal 5. Have as its main purpose the provision of hospice
FDA standards that has the same active ingredients as the services,
original Brand Name Drug Or Supply and is classified as a
6. Have a full-time administrator,
generic by a nationally recognized source and recognized by
us as a Generic Drug Or Supply. 7. Maintain written records of services given to the patient,
and
GENERIC EQUIVALENT
A Generic Drug Or Supply that is therapeutically equivalent 8. Maintain malpractice insurance coverage.
to the Brand Name Drug Or Supply and that meets the For purposes of this Plan, a Home Health Agency that
composition, safety, strength, purity, and quality standards of provides hospice care in the home or a hospice, which is part
the federal FDA and that we require be substituted for a of a Hospital, will be considered a Hospice.
Brand Name Drug Or Supply. Not all Brand Name Drugs
HOSPITAL
with Generic Equivalents are required to be substituted.
An institution duly licensed as a hospital by the
HEALTH SERVICES governmental authority having jurisdiction and a mobile field
Those diagnostic and therapeutic, medical, surgical, and hospital when isolation care and Emergency Services are
mental health services and supplies that are Medically provided.
Necessary and available to you and your Eligible Dependents
under this Plan. Health Services must be provided or
rendered by a licensed health care provider within the scope
of his/her its license or authorization in accordance with the
laws and regulations of the governmental authority having
jurisdiction.
Page 76
HOSPITALIZATION INSUFFICIENT EVIDENCE OF THERAPEUTIC
Health Services rendered by a Hospital as either: VALUE
Insufficient Evidence Of Therapeutic Value occurs when we
Inpatient Hospitalization: Those services rendered to a
patient while that patient is assigned to a specific bed and determine that either:
location, and registered as an "inpatient" at a Hospital, or 1. There is not enough evidence to prove that the service,
Partial Hospitalization/Day Treatment Program: supply, device, procedure or medication (collectively
Those covered behavioral health services which are called “Treatment”) directly results in the restoration of
rendered in a facility or Hospital-based program that health or function for the use for which it is being
provides services for at least 20 hours per week. prescribed, whether or not alternative Treatments are
available, or
HOSPITAL OUTPATIENT SURGICAL FACILITY
(HOSF) 2. There is not enough evidence to prove that the
A facility owned by a Hospital or hospital system offering a Treatment results in outcomes superior to those achieved
with reasonable alternative Treatments which are less
surgical procedure and related care that in the opinion of the
intensive or invasive, or which cost less and are at least
attending physician can be safely performed without
equally effective for the use for which it is being
requiring overnight inpatient Hospital care. A HOSF is
included within the Hospital license and the Medicare or prescribed.
Medicaid certification of the Hospital itself. Services There may be Insufficient Evidence Of Therapeutic Value
rendered by the HOSF are billed utilizing the Hospital’s own for a Treatment even when a Treatment has been approved
tax identification number or a tax identification number by a regulatory body or recommended by a health care
unique to the Hospital or hospital system. practitioner, and the Treatment will not be covered.
INDIVIDUAL PRACTICE ASSOCIATION OR IPA INTENSIVE OUTPATIENT (IOP)
An individual practice association or other organization of The level of behavioral health care which is less intensive
providers, including but not limited to a physician-hospital than Partial Hospitalization, but more intensive than
organization (PHO) and a group practice that has entered outpatient services. Typically, IOP services are customized to
into a services arrangement with us or an affiliate or meet the individual patient’s needs, but have the capacity for
subcontractor of ours to provide Health Services to a maximum of three to five encounters per week of less than
Members under this Plan. four hours each in duration. The range of services offered is
designed to address a mental health or substance abuse
INFERTILITY
disorder in a coordinated, interdisciplinary treatment
The condition of an individual who is unable to conceive or modality.
produce conception or sustain a successful pregnancy during
a period of one year or such treatment is Medically MAXIMUM ALLOWABLE AMOUNT
Necessary. The amount on which we base our reimbursement for
covered Health Services provided by Non-Participating
IN-NETWORK LEVEL OF BENEFITS
providers, which may be less than the amount billed for
Generally, the maximum level of benefits under this Plan those covered Health Services. We calculate the Maximum
available for Health Services provided to a Member directly Allowable Amount as the lesser of the amount billed by the
by his/her Primary Care Provider (PCP) or upon Referral Non-Participating Provider or, where applicable, the amount
from his/her PCP (if you are enrolled in our POS Personal determined by one of the methods described below. In
Care Plan (a Plan that requires Referrals) to a Participating addition, the Maximum Allowable Amount is not the
Provider. The In-Network Level Of Benefits under this Plan amount that we pay for a covered Health Service. The actual
is described in the Member’s Benefit Summary. payment will be reduced by applicable Deductibles(s),
Coinsurance, Copayment(s), Benefit Reduction amounts and
other applicable adjustments described in this document. In
no case will our reimbursement exceed the maximum benefit
described in this document.
We have the sole authority to determine what we use for the
Maximum Allowable Amount. The Maximum Allowable
Amount can change from time to time, as well as the criteria
we will use to determine the Maximum Allowable Amount.
Page 77
Only charges that you are legally required to pay for a Health 5. Where prescription drugs (e.g., IV therapy claims) are
Service will count towards the Maximum Allowable Amount. administered by a Non-Participating Provider, and
So, if the physician or provider is not charging you for part covered as a medical benefit, we will determine the
or all of the Health Service and you are therefore not legally Maximum Allowable Amount using the Average
obligated to pay for that waived amount, we will not count Wholesale Price (AWP), as determined by us.
that waived amount towards the Maximum Allowable 6. For a prescription drug or supply obtained at a pharmacy,
Amount. the Maximum Allowable Amount will be the lesser of the
1. We may contract with vendors that have fee actual charge for the medication or supply or the
arrangements with Non-Participating Providers (Third negotiated contracted rate for that medication or supply
Party Networks). If you utilize a Non-Participating that we would have paid, if the medication or supply had
Provider in a Third Party Network, the Maximum been obtained at a Participating Pharmacy.
Allowable Amount will be determined based on our 7. For Dental Services, the amount of a provider’s billed
contract with the Third Party Network. Where the terms charge for a Dental Service, which we use to determine
of our contract with the Third Party Network require, we what we reimburse under this Plan is the Maximum
will use the contract fee between the Non-Participating Allowable Amount. Only charges that you are legally
Provider and the Third Party Network as the Maximum required to pay for a Dental Service will count towards
Allowable Amount. For other arrangements, we will the Maximum Allowable Amount. So, if the Dentist or
determine the Maximum Allowable Amount as the lesser provider is not charging you for part or all of the Dental
of the contract fee, or billed charges or the amount Service and you are therefore not legally obligated to pay
determined by one of the methods described below. for that waived amount, we will not count that waived
2. We may, at our option, refer a claim for the Out-Of- amount towards the Maximum Allowable Amount.
Network Level Of Benefits covered Health Service to a In the event that the billed charges for the Non-Participating
fee negotiation service to negotiate the Maximum Provider are more than the Maximum Allowable Amount,
Allowable Amount with the Non-Participating Provider. you are responsible for any amounts charged in excess of the
In that situation, if the Non-Participating Provider agrees Maximum Allowable Amount, except where the Non-
to a negotiated Maximum Allowable Amount, you will Participating Provider’s fee is determined by references to a
not be responsible for the difference between the Third Party Network contract or the Non-Participating
Maximum Allowable Amount and the billed charges. You Provider agrees to a negotiated Maximum Allowable
will be responsible for any applicable Deductible(s), Amount.
Coinsurance and/or Copayment(s) at the Out Of
Network Level Of Benefits, as well as any Benefit Whenever you obtain covered Health Services from a Non-
Reduction amounts. Participating Provider, you are responsible for applicable
Deductibles(s), Coinsurance, Copayment(s) and/or Benefit
3. For physician and other professional covered Health Reduction Amounts.
Services, we may utilize a designated percentage of
Resource Based Relative Value System (RBRVS) MEDICAID
determined by us based on a percentage of Medicare. A government program, sponsored by the federal
When no amount specified by the Centers for Medicare government and the individual states, including Connecticut,
and Medicaid Services (CMS) at a percentage of RBRVS which provides coverage for people with lower incomes,
exists, a percentage of charges, as determined by us, will older people, people with disabilities, and some families and
be used instead. children. Beginning in 2014, most adults under age 65 with
individual incomes up to about $15,000 per year will qualify
4. For inpatient and outpatient Hospital covered Health
for Medicaid in every state.
Services, we may utilize a method developed by a
company that uses Hospital cost to charge (C2C) ratio.
This method analyzes charges based upon the Hospitals’:
financial and statistical information as submitted to the
federal government; cost of providing covered Health
Services; and the median mark up by revenue center for
Hospitals in that geographic area. These values are then
compared to the actual billed charges. If the Hospital
accepts the C2C determination, it will become the
Maximum Allowable Amount for the services rendered,
at that time.
Page 78
MEDICALLY NECESSARY OR MEDICAL MEDICARE
NECESSITY Title XVIII of the Social Security Act, including
Medical Health Services that a health care practitioner, amendments.
exercising prudent clinical judgment, would provide to a
MEMBER, YOU, AND YOUR ELIGIBLE
patient for the purpose of preventing, evaluating, diagnosing
DEPENDENTS
or treating an illness, injury, disease or its symptoms, and that
A person enrolled in this Plan, including you and your
are:
Eligible Dependents.
1. In accordance with generally accepted standards of
MINIMUM ESSENTIAL COVERAGE
medical practice,
Any of the following government sponsored programs:
2. Clinically appropriate, in terms of type, frequency, extent,
site and duration and considered effective for the • Medicare,
patient's illness, injury or disease, and • Medicaid,
3. Not primarily for the convenience of the patient, • CHIP,
physician or other health care provider and not more
costly than an alternative service or sequence of services • TRICARE for Life, veteran's health care program),
at least as likely to produce equivalent therapeutic or • Coverage under an eligible employer-sponsored plan,
diagnostic results as to the diagnosis or treatment of that
• Coverage under a health plan offered in the individual
patient's illness, injury or disease.
market within a State, or
For the purposes of this definition, "generally accepted
• Coverage under a grandfathered health plan, and such
standards of medical practice" means standards that are
other health benefits coverage, such as a State health
based on credible scientific evidence published in peer-
benefits risk pool, or as the Secretary of HHS
reviewed medical literature generally recognized by the
recognizes.
relevant medical community or otherwise consistent with the
standards set forth in policy issues involving clinical NEW TREATMENTS
judgment. New Treatments are new supplies, services, devices,
procedures or medications, or new uses of existing supplies,
When used with Dental Services, Medically Necessary means services, devices, procedures or medications, for which we
a necessary dental procedure or service as determined by a have not yet made a coverage policy.
Dentist to either establish or maintain a patient's oral health.
Such determinations are based on the professional diagnostic NON-PARTICIPATING HOSPITAL
judgment of the Dentist and the standards of care that A Hospital that is not a Participating Hospital.
prevail in the professional community. The practitioner NON-PARTICIPATING PHARMACY
determines the care, but coverage of the care under this Plan
A pharmacy that does not have a contract with us to provide
is subject to Dental Necessity as determined by us. We use
covered prescription drugs and supplies to you and your
input from local Dentists, including specialists, to approve,
Eligible Dependents.
and in some cases develop our Dental Necessity protocols.
A Non-Participating Pharmacy is a pharmacy that when used
To be Medically Necessary, dental treatment must be:
by a Member typically provides the lowest level of benefits,
For illness or injury: This means the treatment must be because out of pocket Cost-Shares are the highest.
for a diagnosis that is commonly recognized as a disease
NON-PARTICIPATING PHYSICIAN OR NON-
or injury,
PARTICIPATING PROVIDER
Therapeutic: This means there must be a reasonable A health care practitioner or facility that does not have a
expectation the treatment will directly result in the contract with us to provide Health Services to you. You may
restoration of health or function, pay more to see a Non-Participating Provider.
Required: This means there must be no reasonable
alternative treatment which is less intensive or invasive,
or which costs less and is at least equally effective,
Not Experimental Or Investigational: and
Not elective and not for Cosmetic Treatment
purposes.
Page 79
OUT-OF-NETWORK LEVEL OF BENEFITS PARTICIPATING PHYSICIAN
Generally, a lesser level of benefits than the In-Network A health care professional duly licensed to practice as a
Level Of Benefits under this Plan available for Health physician who has entered into an agreement with us, an
Services provided to a Member when the Health Services are IPA, or an affiliate or a subcontractor of ours to provide
not eligible for benefit coverage at the In-Network Level Of certain Health Services to you and your Eligible Dependents.
Benefits. Except in cases of Emergencies or as otherwise
A Participating Physician is a provider who when used by a
provided in this document, Health Services obtained from or
Member typically provides a higher level of benefits, because
arranged by Non-Participating Providers are payable at the
out-of-pocket Cost-Shares are lower.
Out-Of-Network Level Of Benefits. The Out-Of-Network
Level Of Benefits for benefits under this Plan is the PLAN
Coinsurance percentage described in the Member’s Benefit The program, which is operated by us providing coverage for
Summary multiplied by the Maximum Allowable Amount Health Services to Members.
charges after any Copayments or Deductible is applied. If the
PLAN BENEFITS
Out-Of-Pocket Maximum is met for a Member in a year,
Health Services covered as specified in this document.
then the Out-Of-Network Level Of Benefits is modified as
described in the definition of Out-Of-Pocket Maximum for POLICY
the remainder of that year. This document, and including the Benefit Summary, Riders,
OUT-OF-POCKET MAXIMUM insert pages, Exchange enrollment form.
Generally, the maximum Cost-Share amount a Member pays PRE-AUTHORIZATION OR PRE-AUTHORIZED
per year for Health Services, as listed in the Member’s The authorization, based on Medical Necessity, needed from
Benefit Summary. us, or the applicable Delegated Program, in advance of the
PARTICIPATING HOSPITAL Member’s receipt of certain specified Health Services.
A select Hospital that has entered into an agreement with us, Pre-Authorization also includes the written authorization
an IPA or an affiliate or subcontractor of ours to provide from us, or the applicable Delegated Program, needed in
certain Health Services to you and your Eligible Dependents. advance of the Member’s receipt of Health Services from a
Non-Participating Provider in order to have those services or
A Participating Hospital is a Hospital that when used by a
supplies covered at the highest level of benefits under the
Plan.
PRE-CERTIFICATION OR PRE-CERTIFIED
PARTICIPATING PHARMACY
The registration and approval process, based on Medical
A select pharmacy that has entered into an agreement with
Necessity, needed in advance of the Member’s Partial
us, an IPA or an affiliate or subcontractor of ours to provide
Hospitalization or inpatient admission to a Hospital,
covered prescription drugs, medications and supplies to you
Hospice, Residential Treatment Facility, Rehabilitation
and your Eligible Dependents.
Facility or Skilled Nursing Facility that is obtained from us,
A Participating Pharmacy is a pharmacy that when used by a or the applicable Delegated Program.
PREMIUM
The regular payments required to be made to us by you
A Participating Pharmacy does not include a Hospital under this Plan for coverage to remain in effect.
pharmacy, even if the Hospital is a Participating Hospital.
PREMIUM PERIOD
PARTICIPATING PROVIDER The span of time which begins at either the first of the
A select health care practitioner or facility, including a month based on your Effective Date and ends one month
Dentist, Participating Physician, Participating Pharmacy, later.
Participating Hospital or other similar practitioner or facility,
that is duly licensed to provide Dental Services or health care PRIMARY CARE PROVIDER OR PCP
services and that has entered into an agreement with us, an A physician, advanced practice registered nurse (APRN), or
IPA or an affiliate or a subcontractor of ours to provide a nurse practitioner who is a Participating Provider selected
certain Health Services to you and your Eligible Dependents. by or assigned to the Member, who is normally engaged in
one of the following primary care specialties:
A Participating Provider is a provider who when used by a
Member typically provides a higher level of benefits, because • Family medicine,
out-of-pocket Cost-Shares are lower. • Internal medicine,
Participating Providers do not include Hospital-based clinics, • Pediatrics, and
even if the Hospital is a Participating Hospital, unless the who is eligible to be listed as a PCP in the Provider
Hospital clinic is specifically contracted with us. Directory.
Page 80
PROVIDER DIRECTORY RESIDENTIAL TREATMENT FACILITY
The listing of Participating Providers compiled and prepared A treatment center for children and adolescents that
for our benefit plans. provides residential care and treatment for emotionally
disturbed individuals and is licensed and accredited by the
PRUDENT LAYPERSON
governmental authority having jurisdiction.
A person who is without medical training and who draws on
his/her practical experience when making a decision RIDER
regarding whether Emergency medical treatment is needed. A written amendment that modifies the terms and conditions
A Prudent Layperson will be considered to have acted of this document.
“reasonably” if other similarly situated laypersons would
SERVICE AREA
have believed, on the basis of observation of the medical
Those geographic areas where Participating Providers
symptoms at hand, that Emergency medical treatment was
provide benefits for covered Health Services as described in
necessary.
this Policy.
QUALIFIED HEALTH PLAN OR QHP
SKILLED NURSING FACILITY
A health plan that has in effect a certification issued or
An institution or distinct part of an institution that is duly
recognized by each Exchange through which such health
licensed as a skilled nursing facility by the governmental
plan is offered.
authority having jurisdiction.
QUALIFIED HEALTH PLAN ISSUER OR QHP
SPECIALIST PHYSICIAN
ISSUER
A physician specialist (other than the Member’s PCP) who
A health plan insurance issuer that offers a QHP in
focuses on a specific area of medicine or a group of patients
accordance with the certification from an Exchange.
to diagnose, manage, prevent or treat certain types of
QUALIFIED INDIVIDUAL symptoms and conditions. A non-physician specialist is a
With respect to an Exchange, an individual who has been provider who has more training in a specific area of health
determined eligible to enroll through the Exchange in a QHP care.
in the individual market.
SUBSCRIBER OR YOU
RADIOLOGY SERVICES PROGRAM You, when you are enrolled in this Plan and eligible to
A Delegated Program under which we may provide for receive Plan Benefits.
management, administration and a network of providers for
You will also be considered the Subscriber in the case of
outpatient diagnostic x-rays and therapeutic procedures child only coverage, where this Policy has been issued in
under this Plan. In some instances the Radiology Services
your name. When that child only Policy has been issued to
Program may be managed and administered by a Delegated
you, it is your responsibility to assure a child complies with
Program under contract with us. In that event, when this
any and all the terms and conditions outlined in this Policy.
document refers to determinations, Pre-Authorizations, and
other decisions made under the terms of the Radiology SURPRISE BILL
Services Program, such determinations, Pre-Authorizations, A bill for health care services, other than Emergency
and other decisions are made by the Delegated Program on Services, that you receive for services rendered by a Non-
behalf of us. Participating Provider, where those services were rendered
by a Non-Participating Provider at a Participating Provider
REFERRAL
facility, during a service or procedure performed by a
An approval communicated to us by the Member’s Primary
Participating Provider during a service or procedure
Care Provider (PCP) (or the covering physician designated
previously Pre-Certified or Pre-Authorized by us and you did
by the Member’s PCP), which the Member must obtain prior not knowingly elect to obtain those services from the Non-
to his/her receipt of health care services from Specialist
Participating Provider.
Physicians and other Participating Providers in order to be
eligible for benefits at the highest level of benefits. A Surprise Bill does not include a bill for health care services
received by you when a Participating Provider was available
REHABILITATION FACILITY to render the services and you knowingly elected to obtain
A Hospital or other facility that provides restorative physical the services from a Non-Participating Provider.
and occupational therapy treatment and is licensed and
accredited as a rehabilitation facility by the governmental or TELEMEDICINE
other authority having jurisdiction. Telemedicine is the use of interactive audio, interactive video
or interactive data communication in the delivery of medical
RENEWAL DATE advice, diagnosis, care or treatment.
January 1st of each year whereby coverage under this Policy is
continued subject to the terms of this Policy, as long as the Telemedicine does not include the use of electronic mail,
Subscriber pays the Premium due. facsimile, texting or audio-only telephone.
Page 81
URGENT CARE NON-DISCRIMINATION DISCLOSURE
Health Services for the treatment of a sudden and
unexpected onset of illness or injury requiring care within 24
ADDENDUM
hours that can be treated in a physician’s office or in an ConnectiCare complies with applicable federal civil rights
Urgent Care Center. laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. ConnectiCare does not
URGENT CARE CENTER exclude people or treat them differently because of race,
A facility duly licensed to provide Urgent Care. color, national origin, age, disability, or sex.
UTILIZATION MANAGEMENT ConnectiCare:
The process of evaluating and determining the coverage for
and the appropriateness of medical care services, as well as • Provides free aids and services to people with
providing any needed assistance to the clinician or the disabilities to communicate effectively with us
patient in cooperation with other parties, to ensure including qualified interpreters and information in
appropriate use of resources. Utilization Management alternate formats, and
includes Pre-Authorization or Pre-Certification, concurrent • Provides free language services to people whose
review, retrospective review, discharge planning and Case primary language is not English, including translated
Management. documents and oral interpretation.
WALK-IN CARE CLINIC If you need these services, contact The Committee for Civil
A facility designed to treat common ailments. Examples of Rights.
common ailments include, but are not limited to: If you believe that ConnectiCare has failed to provide these
• Colds, flu symptoms, sore throat, cough or upper services or discriminated in another way on the basis of race,
respiratory symptoms, color, national origin, age, disability, or sex, you can file a
grievance with: The Committee for Civil Rights,
• Ear or sinus pain, ConnectiCare, 175 Scott Swamp Road, Farmington, CT
• Minor cuts, bruises, or scrapes 06034, 1-800-251-7722, and TTY number 1-800-833-8134.
You can file a grievance in person at 175 Scott Swamp Road,
• Rash, hives, stings and bites, and
Farmington, CT, or by mail, or fax (860) 674-2232. If you
• Sprains need help filing a grievance, The Committee for Civil Rights
Walk-In Care Clinic provide basic primary health care and is available to help you. You can also file a civil rights
are typically staffed by a nurse practitioner or at the most complaint with the U.S., Department of Health and Human
physician’s assistant. Services, Office for Civil Rights, electronically through the
Office of Civil Rights Complaint Portal, available at:
WILDERNESS CAMP https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail
A camp that provides behavioral health intervention for or phone at:
children and adolescents with emotional, addiction, and or
psychological problems. The intervention typically involves U.S. Department of Health and Human services
immersion in the wilderness or wilderness like setting, group 200 Independence Avenue, SW
living with peers, the administration of individual and group
therapy sessions, and educational/therapeutic curricula, Room 509F, HHH Building
including back country travel, wilderness living skills and Washington, DC 20201
horseback riding.
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at:
http://www.hhs.gov/ocr/office/file/index.html.
Page 82
PATIENT PROTECTION AND Utilization Review Data
AFFORDABLE CARE ACT (PPACA) ConnectiCare Benefits, Inc.
ADDENDUM Requests for 30,595
Certification
PRIMARY CARE PROVIDERS (PCP)S
ConnectiCare generally allows the designation of a Primary Certification Denials 3,970 (13.0%)
Care Provider (PCP). You have the right to designate any Number of Appeals of 222 (5.6%)
PCP who participates in our network and who is available to Denials
accept you or your family members. For information on
how to select a PCP, and for a list of the PCP Participating Number of Denials 93 (41.9%)
Providers, visit our website at www.connecticare.com or call Reversed Upon Appeal
us at (860) 674-5757 or 1-800-251-7722. Below are the medical loss ratios for 2016.
For children, you may designate a pediatrician as the PCP. Medical Loss Ratios
You do not need Pre-Authorization from ConnectiCare or ConnectiCare Benefits, Inc.
from any other person (including a PCP) in order to obtain
access to obstetrical or gynecological care from a health care State Medical Loss Ratio
professional in our network who specializes in obstetrics or 96.1%
gynecology. The health care professional, however, may be
required to comply with certain procedures, including Federal Medical Loss Ratio
obtaining Pre-Authorization or Pre-Certification for certain 86.5%
services, following a pre-approved treatment plan, or
Quality Improvement Program
procedures for making Referrals. For a list of Participating
Providers who specialize in obstetrics or gynecology, visit 1. Based on the H EDIS (H ealthcare Effectiveness Data
our website at www.connecticare.com or call us at (860) 674- and Information Set) CAH PS (Consumer
5757 or 1-800-251-7722. Assessment of H ealthcare Providers and Systems)
Member Satisfaction study for 2016, 59.5% of our
PLAN DESCRIPTION ADDENDUM Members gave us an 8 or above when they were asked to
This addendum, in conjunction with this document, any rate our health plan on a scale ranging from worst health
Rider and the Provider Directory constitutes compliance plan (“0”) to the best health plan (“10”).
with the disclosure requirements of Connecticut law, “AN 2. ConnectiCare makes information about its Quality
ACT CONCERNING MANAGED CARE,” regarding Plan Improvement Program available to all Members,
Descriptions. including information about the quality information
We are a for-profit health care center, organized under the program, including goals, processes and outcomes as they
Connecticut Business Corporations Act. If our status should relate to Member health and service. You may access this
change, you will be notified in our member newsletter. information at www.connecticare.com. If you would like
a written copy, you should call our Member Services
We are also accredited by the National Committee for Department.
Quality Assurance (NCQA).
3. Connecticut law requires the State of Connecticut
The following information is a summary of our 2016 Insurance Department to develop and distribute a
utilization review data with respect to the number of consumer report card, which compares:
certifications requested; the number of admissions, services,
procedures or extension of stays not certified; and the • All licensed managed care organizations, and
number of denials upheld or reversed on • The 15 largest licensed health insurers that use
Appeals/Grievances within our utilization review process. provider networks not included above.
This information includes review data for benefits managed
or administered by an outside company under its own
Connecticut utilization review license.
Page 83
PRE-AUTHORIZATION AND PRE- Hospital clinics, non-contracted or out of the Service
Area
CERTIFICATION (PRIOR APPROVAL) HIV Lipodystrophy Syndrome (if a covered benefit)
ADDENDUM Interventional Pain Management Services for Chronic
You Need Pre-Authorization Or Pre-Certification For Back pain (including, - facet and epidural injection,
The Following: minimally invasive spine procedures and pain pumps)
Admissions: Mammoplasty (breast augmentation or reduction)
Hospital admissions that are elective or not the result of Noncoronary stents
an Emergency, including: Acute Hospitals admissions* Oncotype DX breast cancer test
Partial Hospitalizations Programs (PHP)* Oral appliances for the treatment of Obstructive Sleep
Rehabilitation Facility admissions* Residential Apnea
Treatment Facilities* Oral surgery (if a covered benefit)
Skilled Nursing Facility admissions Osteochondral grafting
Sub-acute care admissions Reconstructive surgery (not applicable to reconstructive
Ambulance/Medical Transportation: surgery in conjunction with a mastectomy for breast
Land or air ambulance/medical transport that is not due cancer)
to an Emergency Septoplasty
Durable Medical Equipment (DME) Solid organ transplants (except cornea) and bone marrow
Pre-Authorization will only be required for the following transplants (all transplant Pre-Authorizations must be
items (if a covered benefit): customized wheelchairs done at least ten business days prior to services being
and scooters, functional electric/neuromuscular rendered)
electric stimulators, high frequency chest wall Spine Surgery Procedures (open and minimally invasive)
oscillation devices, osteogenic stimulators (including including Artificial Intervertebral Disc (if a covered
spinal, non-spinal and ultrasound) benefit)**
Elective Services & Procedures: Transvascular Autonomic Modulation (TVAM) for
Applied Behavioral Analysis (ABA) for the treatment of autonomic dysfunction (balloon angioplasty devices)
Autism Spectrum Disorder (ASD) (if a covered Varicose vein surgery (if a covered benefit)
benefit)* Ventricular Assist Devices
Clinical trials Virtual Colonscopy
Cardiac monitoring with Mobile Cardiac Outpatient Home Health Care:
Telemetry or continuous computerized daily Home health services
monitoring with auto-detection (no Pre-Authorization Hospice care
is required for standard Holter monitors or loop event Infertility Services
recording devices) Intensive Outpatient Treatment Programs (IOP*)
Cologuard Colorectal Screening Insufficient Evidence of Therapeutic Value
Craniofacial treatment Services, supplies, devices, or procedures for which there
Gastric bypass surgery, including laparoscopic (if a is Insufficient Evidence Of Therapeutic Value (New
covered benefit) Technology Guidance on Provider website -
Gastric electrical stimulation https://www.connecticare.com/providers/pdfs/new
Gender Reassignment Surgery %20technology%20guidance.pdf)
Genetic testing - only the following genetic testing does Interventional Cardiology
not require Pre-Authorization: Including Implantable Cardiac Defibrillators,
Routine chromosomal analysis (e.g., peripheral blood Pacemakers, Heart Catheterizations
or tissue culture, chorionic villus sampling, Neuropsychological Testing (behavioral health* and
amniocentesis), medical purposes) except for neuropsychological testing
Chromosomal microarray analysis for children/adults, ordered by a doctor to determine the extent of any cognitive
FISH testing for lymphoma or leukemia, and or developmental delays due to chemotherapy or radiation
Molecular pathology analyses for Cystic Fibrosis, treatment in a child diagnosed with cancer or as described in
Factor V Leiden, Prothrombin, Hereditary your Policy.
Hemochromatosis and Fragile X
eClipse vaginal insert for fecal incontinence treatment
Functional Electrical Stimulation and Neuromuscular
Electrical Stimulation
Functional endoscopic sinus surgery
Gynecomastia surgery (if a covered benefit)
HeartFlow analysis system
Page 84
Outpatient Radiological Services (except when such Afstyla
radiological services are done in conjunction with a Aldurazyme
biopsy or other surgical procedure):** Alcortin
Radiation Therapy for Cancer, including Proton Beam Alecensa
Therapy Alimta
Stereotactic Radiosurgery and Stereotactic Body Aloquin
Radiation Therapy for all diagnosis Alsuma
Bone mineral density exams ordered more frequently Altoprev
than every 23 months Alvesco
CT scans (all diagnostic exams) Amjevita
MRI/MRA (all examinations) Ampyra
Nuclear cardiology Amrix
PET scans Anastia
Stress echocardiograms Androderm
Transesophageal Echocardiology Androgel
Transthoracic Echocardiology Anzemet
Outpatient Rehabilitative Services: Apidra
Occupational therapy Aplenzin
Physical therapy Apokyn
Speech therapy (including specialty Hospitals, acute care Aralast
Hospitals and providers of rehabilitation services) Arcalyst
Outpatient Electro-Convulsive Treatment (ECT)* Aricept 23
Outpatient psychotherapy lasting 60 minutes or longer Aricept ODT
(53+ min, per the CPT time rule) * Arnuity Ellipta
Psychological Testing Over 5 Hours (1 to 5 hours Arthrotec
requires notification only)* Arymo ER
Transcranial Magnetic Stimulation* Arzerra
*Pre-Authorization is conducted by OptumHealth Asacol/HD
Behavioral Solutions - 1-888-946-4658 Ascensia Test Strips
Aubagio
**Pre-Authorization is conducted by NIA Magellan – Auvi-Q
1-877-607-2363 Avar/Avar Plus
Avastin
You Need Pre-Authorization For The Following
Aveed
Prescription Drugs:
Avidoxy
You Need Pre-Authorization For The Following Avonex
Prescription Drugs: Axiron
Abilify Discmelt Beconase AQ
Absorica Belbuca
Abstral Belsomra
Accu-chek test strips Bendeka
Aciphex Benlysta
Actemra Berinert
Acthar Gel Betaseron
Acticlate Bevespi Aerosphere
Actimmune Blincyto
Actiq Blood Clotting Factors (All)
Actoplus Met XR Boniva Injection
Acne-Brand Name Oral Agents; Doryx, Dynacin, Adoxa, Bosulif
Myrac, Soladyn, Minocin PAC Botox
Adcetris Bravelle
Adcirca Breo Ellipta
Adempas Bunavail
Adlyxin Buphenyl
Adoxa Buprenorphine/Naloxone Tabs
Advair Bydureon
Afinitor Byetta
Afrezza
Page 85
Bystolic Edluar
Byvalson Egrifta
Cabometyx Elaprase
Cambia Elelyso
Caprelsa Eloxatin
Cardizem LA Embeda
Cardura XL Emflaza
Cayston Empliciti
Cerdelga Enbrel
Cerezyme Endometrin
Cesamet Enstilar
Cetrotide Entresto
Cholesterol Lowering Drugs: Altoprev, Lescol/XL, Entyvio
Cimzia Epaned
Cinqair Epclusa
Cinryze Epiduo Forte
Clarinex / D Erbitux
Clobetasol Erelzi
Clobex Erivedge
Cloderm Esbriet
Clolar Eucrisa
CNL Nail kit Euflexxa
Coartem Exelon/Exelon patch
Cometriq Exjade
Compounded Medications Exondys 51
Contraceptives Extavia
Copaxone Fabrazyme
Cordran Fanapt
Corlanor Farxiga
Cosentyx Farydak
Cotellic Feiba
Cuvitru Fenoglide
Cuvposa Fentora
Cyramza Fetzima
Dacogen Fexmid
Daklinza Fibrocor
Daliresp Firazyr
Daraprim Flector Patch
Darzalex Flolan
Daxbia Flovent
Delzicol Flowtuss
Desvenlafaxine Fumarate Fluoxetine 60mg capsules
Dexilant Follistim AQ
Differin Folotyn
Dificid Fortamet
Dipentum Fortesta
Doryx Forfivo XL
Dovonex Fulyzaq
Doxepin cream Fuzeon
Duetact Ganirelix
Duexis Gattex
Durlaza Gazyva
Dymista Gelnique
Dysport Gel-One
Ecoza Gelsyn-3
Edarbi Genotropin
Edarbyclor Genvisc 850
Page 86
Gilenya Kalbitor
Gilotrif Kalydeco
Glassia Kanuma
Glatopa Kazano
Gleevec Kerydin
Gleostine Keveyis
Glumetza Keytruda
Glyxambi Khedezla
Gonal-F Kineret
Gralise Kombiglyze XR
Grastek Korlym
Growth Hormones (All) Kovaltry
Halaven Krystexxa
Harvoni Kuvan
Herceptin Kynamro
Hetlioz Kyprolis
Hizentra Kytril
Horizant Lamictal XR
Humatrope Lartruvo
Humira Latuda
Hyalgan Lazanda
Hycamtin Lemtrada
Hycofenix Lenvima
Hyqvia Letairis
Hysingla ER Lialda
Ibrance Livalo
Iclusig Livixil
Ilaris Lofibra
Imbruvica Lonsurf
Imlygic Lovaza (formerly Omacor)
Impavido Lumigan
Increlex Lumizyme
Incruse Ellipta Luveris
Inderal XL Luzu
Infertility Medications (All) Lynparza
Inflectra Lyrica
Injectable Drugs (All): excluding insulin Macugen
Inlyta Marqibo
Interferons (All) Matzim LA
Intron-A Mekinist
Invokamet/XR Mefloquine
Invokana Menopur
Irenka Mepron
Iressa Mesalamine 800mg DR
Istodax Metformin ER (OSM and MOD)
IV Immune Globulin (IVIG) Metoprolol HCTZ
Ixempra Minocin Combo Pack
Jadenua Mircera
Jakafi Monovisc
Janumet/Janumet XR Mozobil
Januiva Myobloc
Jardiance Myozyme
Jetrea Myrac
Jevtana Myrbetriq
Jublia Naglazyme
Juxtapid Namenda
Kadcyla Namzaric
Page 87
Nasacort AQ Patanase
Natesto Pegasys
Natpara Peg-Intron
Nesina Pennsaid
Nexavar Pentasa
Nexium Perjeta
Nimodipine Pexeva
Ninlaro Plegridy
Norditropin Pomalyst
Northera Portrazza
Novacort Praluent
Novolin/Novolog Prestalia
Novoseven Prevacid (Rx)
NPlate Prialt
Nucala Prilosec (Rx)
Nuedexta Pristiq
Nulojix Probuphine
Numbonex Prolastin
Nuplazid Proleukin
Nutropin/AQ Prolia
Nuvigil Procysbi
Ocaliva Promacta
Odomzo Protonix (brand)
Ofev Provenge
Oforta Proventil HFA
Oleptro Provigil
Olux Prozac Weekly
Olux E Prudoxin Cream
Olysio Psorcon
Omnaris Pulmicort
Omnitrope Qbrelis
One Touch Test Strips Qnasl
Onexton Qualaquin
Onglyza Qudexy XR
Onmel Qutenza
Onzetra Xsail Ragwitek
Opana ER Rapaflo
Opdivo Rasuvo
Opsumit Ravicti
Oracea Razadyne
Oralair Rayaldee
Oravig Rebif
Orencia Regranex
Orenitram Relistor
Orfadin Relpax
Orkambi Remicade
Orthovisc Remodulin
Oseni Repatha
Otezla Repronex
Otrexup Retisert
Ovace Revatio
Oxaydo Revlimid
Oxtellar XR Rexulti
Oxycodone AG RiaStap
Oxycontin Rituxan
Oxytrol Rixubis
Ozurdex Rosula
Page 88
Rubraca Testosterone (All)
Ruconest TevTropin
Saizen Thalomid
Sanctura Thyrogen
Sancuso Tivorbex
Saphris Torisel
Savella Toviaz
Seebri Neohaler Tracleer
Sernivo Tramadol Biphasic
Signifor Travatan/Travatan Z
Silenor Travel Medication: including Malarone, Larium and
Simponi/Simponi ARIA Aralen
Sitavig Treanda
Soliqua Trelstar
Solodyn Tretin X
Soliris Tretten
Somavert Treximet
Sorilux Triferic
Sovaldi Triglide
Spinraza Trintellix
Spiriva Trokendi XR
Sporanox Troxyca ER
Sprix Trulicity
Sprycel Tuzistra XR
Steroids, Anabolic Tykerb
Stelara Tysabri
Stivarga Tyvaso
Strensiq Unituxin
Striant Uptravi
Subsys Utibron Neohaler
Sucraid Valchlor
Sumavel Dosepro Vanos
Supartz Vantas
Supprelin LA Vascepa
Sustol Vectibix
Sutent Velcade
Sylatron Velphoro
Sylvant Veltassa
Symlin Venclexta
Synagis Ventavis
Synarel Ventolin HFA
Synjardy/XR Veramyst
Synribo Verdeso
Synvisc (hyaluronate sodium) Vesicare
Tagrisso Victoza
Tafinlar Vidaza
Taltz Viekira Pak
Tanzeum Viibryd
Tarceva Vimizim
Targadox Vimovo
Tasigna Vistogard
Tecentriq Vituz
Tecfidera Vivlodex
Technivie Vogelxo
Tekturna Vonvendi
Temodar Votrient
Testim Vpriv
Page 89
Vraylar Specialty Drugs:
Vusion Specialty drugs that require Pre-Authorization should
Vytorin only be filled through specialty pharmacies that are
Weight Loss Medication (if covered by your plan); Participating Pharmacies, unless you qualify for an
Meridia, Xenical, Ionamin, Tenuate, etc exception. The list of specialty drugs that have this
Xalkori requirement is, as follows. If you believe you should be
Xartemis XR eligible for an exception, your provider must complete
Xeljanz/XR a specialty pharmacy exception form and then send it
Xeloda to us via fax at (860) 674-2851 or via regular mail at the
Xenazine following address:
Xeomin ConnectiCare Pharmacy Services
Xiaflex 175 Scott Swamp Road
Xigduo XR Farmington, CT 06032-3124
Ximino
Growth Hormone including:
Xofigo
Accretropin
Xolair
Genotropin
Xopenex HFA
Humatrope
Xtampza ER
Increlex
Xultophy
Norditropin
Xuriden
Nutropin
Xtandi
Nutropin AQ
Xyntha
Omnitrope
Xyrem (Sodium Oxybate)
Saizen
Yervoy
Serostim
Yondelis
TevTropin
Yosprala
Blood Clotting Factors including:
Zaltrap
Advate
Zavesca
Afstyla
Zegerid
Alphanate
Zelboraf
Alprolix
Zemaira
Benefix
Zembrace SymTouch
Helixate
Zenzedi
Humate P
Zepatier
Kogenate FS
Zetonna
Monarc M
Zevalin
NovoSeven
Zinbryta
Recombinate
Zingo
Rixubis
Zioptan
Tretten
Zipsor
Vonvendi
Zohydro ER
Xyntha
Zolinza
Hepatitis C Treatments including:
Zolpimist
Daklinza
Zonalon
Epclusa
Zontivity
Harvoni
Zortress
Infergen
Zorvolex
Olysio
Zubsolv
Peg Intron
Zuplenz
Pegasys
Zurampic
Ribavirin
Zydelig
Sovaldi
Zyflo CR Sylatron
Zykadia Technivie
Zytiga Viekira Pak
Zepatier
Page 90
LHRH Agonists including; Kalydeco
Eligard Kanuma
Lupron Korlym
Trelstar Kynamro
Viadur Krystexxa
Vantas Kuvan
Zoladex Lumizyme
Multiple Sclerosis Treatments including: Mozobil
Ampyra Myobloc
Aubagio Myozyme
Avonex Naglazyme
Betaseron Northera
Copaxone Nplate
Extavia Nucala
Gilenya Nulojix
Glatopa Ocaliva
Plegridy Ofev
Rebif Oralair
Tecfidera Orfadin
Tysabri Orkambi
Zinbryta Ozurdex
Other Drugs including: Praluent
Acthar Prilat
Actimmune Procysbi
Aldurazyme Prolastin
Apokyn Prolia
Aralast Promacta
Aveed Ravicti
Benlysta Repatha
Berinert Retisert
Boniva injection Riastap
Botox (botulinium toxin type A) Ruconest
Cayston Qutenza
Cerdelga Samsca
Cerezyme Sandostatin LAR
Cinqair Signifor
Dysport Soliris
Cinryze Somavert
Egrifta Spinraza
Elaprase Strensiq
Elelyso Sucraid
Emflaza Supprelin LA
Esbriet Sylvant
Exjade Synagis
Exondys Testopel
Fabrazyme Thyrogen
Firazyr Veltassa
Folotyn Vimizim
Gattex Vistogard
Glassia Vpriv
Hetlioz Xenazine
Ilaris Xeomin
IVIG (Immuneglobulin) Xiaflex
Jakafi Xolair
Jetrea Xuriden
Juxtapid Xyrem
Kalbitor Zemaira
Page 91
Zavesca Zydelig
Zemaira Zykadia
Zortress Zytiga
Oral Oncology Agents Including: Psoriasis/Rheumatoid Arthritis/Crohn’s Disease
Afinitor Treatments including:
Alecensa Actemra
Bosulif Amjevita
Cabometyx Arcalyst
Caprelsa Benlysta
Cometriq Cimzia
Cotellic Cosentyx
Erivedge Cuvposa
Gazyva Enbrel
Gilotrif Entyvio
Gleevec Erelzi
Gleostine Humira
Hycamtin Inflectra
Ibrance Ilaris
Iclusig Kineret
Imbruvica Krystexxa
Inlyta Orencia
Iressa Otezla
Jakafi Remicade
Lenvima Rituxan RA
Lonsurf Simponi
Lynparza Stelara
Mekinist Taltz
Nexavar Xeljanz
Ninlaro Pulmonary Hypertension Drugs including:
Odomzo Adcirca
Ofev Adempas
Oforta Flolan
Pomalyst Letairis
Revlimid Opsumit
Sprycel Remodulin
Stivarga Revatio
Sutent Sildenafil
Sylatron Tracleer
Synribo Tyvaso
Tafinlar Uptravi
Tarceva Veletri
Tasigna Ventavis
Temodar Infertility Drugs including:
Thalomid Bravelle
Thiola Cetrotide
Tykerb Follistim AQ
Valchlor Ganirelix
Venclexta Gonal-F
Votrient Menopur
Xalkori Repronex
Xeloda
Xtandi
Zelboraf
Zolinza
Zortress
Page 92
Viscosupplements including:
Euflexxa
Gel-One
Gelsyn-3
Genvisc
Hyalgan
Monovisc
Orthovisc
Supartz
Synvisc
Synvisc One
In addition, any drug that is newly available to the market
will also require Pre-Authorization until such time as we re-
publish our list of drugs requiring Pre-Authorization.
Page 93

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Formati disponibili

Choice Gold Standard POS

Separate Prescription Drug

Out-of-Pocket Maximum $4,400 per Member $8,800 per Member

Benefits IN-NETWORK (INET) OUT-OF-NETWORK (OON)

Provider Office Visits

Adult Preventive Visit No cost 30% coinsurance per visit

Infant/Pediatric Preventive Visit No cost 30% coinsurance per visit

CBI/POS [HIX]/Gold/IND BS (01/2018) 76962CT0010006-01 Effective Date: 1/2018 1

Prescription Drugs - Retail IN-NETWORK (INET) OUT-OF-NETWORK (OON)

Prescription Drugs - Mail Order IN-NETWORK (INET) OUT-OF-NETWORK (OON)

Tier 1 Prescription Drugs $10 copayment per prescription Not covered

Tier 2 Prescription Drugs $50 copayment per prescription Not covered

Tier 3 Prescription Drugs $100 copayment per prescription Not covered

CBI/POS [HIX]/Gold/IND BS (01/2018) 76962CT0010006-01 Effective Date: 1/2018 2

Other Services IN-NETWORK (INET) OUT-OF-NETWORK (OON)

Inpatient Hospital Services IN-NETWORK OUT-OF-NETWORK

CBI/POS [HIX]/Gold/IND BS (01/2018) 76962CT0010006-01 Effective Date: 1/2018 3

Ambulance Services No cost No cost

Pediatric Dental Care IN-NETWORK OUT-OF-NETWORK

Pediatric Vision Care IN-NETWORK OUT-OF-NETWORK

Prescription Eye Glasses Lenses: $0 Not covered

CBI/POS [HIX]/Gold/IND BS (01/2018) 76962CT0010006-01 Effective Date: 1/2018 4

CBI/POS [HIX]/Gold/IND BS (01/2018) 76962CT0010006-01 Effective Date: 1/2018 5

Form: HIX CBI/POS OA IND 01 (1/2018)

Questions When Applying For Coverage Or Questions And Complaints

For example, when a completed Exchange enrollment form

SERVICES REQUIRING PRE-AUTHORIZATION

Colorectal Cancer Screenings There is no coverage for diagnostic breast tomosynthesis

• Immunizations a Member gets only because someone Gynecological Office Services

Benefits • Be Medically Necessary;

• Vision therapy and vision training Workers’ Compensation

CLAIMS FILING • The Subscriber’s name,

Periodontist: A Dentist whose practice is limited to the EMERGENCY SERVICES

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