Broker Quick Reference Now, more than ever, your clients need a plan that provides quality care. It has never been more important for your clients to have quality coverage they can depend on. We listened to your feedback in addition to our members and doctors to provide more of what your clients want: • Nearly TWICE as many providers as last year • Expanded coverage area now includes Middlesex County • PPO plan option giving your clients the freedom to access any doctor and hospital CarePartners of Connecticut High-quality benefit offerings including embedded CarePartners Broker Support dental coverage in all plans. With a CarePartners of 1-860-996-7096 Connecticut Medicare Advantage plan, you can feel [email protected] confident about recommending it to your clients— David Pallotta, FMO Broker Manager knowing they can depend on it when they need it most. 1-860-202-5658 [email protected] Service Area Member Customer Service 1-888-341-1507 Hartford • Litchfield • Middlesex • New Haven • carepartnersct.com New London • Tolland • Windham GarityAdvantage Network Hospitals CPCT Broker Toolbox Backus Hospital • Charlotte Hungerford Hospital • Griffin Hospital • garityadvantage.com/CPCT-Agent-Tools Hartford Hospital • Manchester Memorial Hospital • Middlesex Health Garity Broker Support • MidState Medical Center • Rockville General Hospital • St. Vincent’s 1-800-234-9488 Medical Center • Stamford Hospital • The Hospital of Application submission (Completed online Central Connecticut • Waterbury Hospital • utilizing your personalized URL, uploaded Windham Hospital through Garity Agent Dashboard) garityadvantage.com/agent-dashboard Largest Physician Groups Fax: 1-781-982-1887 Community Medical Group • Connecticut GI Specialists • Integrated Care Physicians • Middlesex Health • Physicians Alliance Application/commission tracking through Greenwave of CT (PACT) • Prospect Medical • Starling Physicians • Women’s Health Connecticut CareAdvantage (HMO) CarePartners Access PPO MOST POPULAR PLAN Prime Premier INN OON Preferred Premium $0 $30 ($0 LIS) $90 ($54.80 LIS) $0 MOOP $7,550 $5,900 $4,700 $7,550 combined Medical Deductible N/A $1,000 combined PCP Copay $0 $0 $201 Specialist Office Visits $45 $40 $30 $45 $501 Inpatient Hospital $475/day for $375/day for $250/day for $795/stay1 30%1 Services days 1–4 days 1–4 days 1–5 Outpatient Hospital $02–$350/day $02–$275/day $02–$250/day $02–$250/day1 30%1 Services $0 PCP/$40 $0 PCP/$30 Urgent Care Visits $0 PCP/$45 Specialist $45 Specialist Specialist Emergency Services $90 $90 Dental Benefits3 Embedded: $1,500 max, Embedded: $750 max, $25 preventive, $1,000 maximum, $0 preventive, 50% Dominion Dental $0 preventive, 50% 50% coinsurance restorative, $100 ded for coinsurance restorative and major services. Customer Service: coinsurance restorative restorative. 888-291-6923 & major services, $100 Optional rider available for comprehensive deductible on restorative coverage with additional $15/month and major services. premium. OTC $25/qtr $40/qtr $40/qtr $50/qtr N/A Eyewear Allowance $150/yr (INN) $150/yr (INN) $150/yr (INN) EyeMed Vision Care $150/yr $90/yr (OON) $90/yr (OON) $90/yr (OON) (Access Network) Weight Management $150/yr N/A SilverSneakers® Included Included N/A SilverSneakers.com Discount Card CVS branded, non- 20% off 20% off presc., health-related merchandise CarePerks Wellness $175/yr N/A N/A Allowance Prescription Drug Coverage for ALL PLANS. Hearing Aids: Hearing Care Solutions No prescription deductibles apply. • One per ear/per year Preferred (30-day supply): T1 $0, T2 $0 (NEW), T3 $47, T4 $100, T5 33%. • Copay of $250, $475, $650, $850, or $1,150 • 3-year supply of batteries, up to 192 cells per ear Standard (30-day supply): T1 $10, T2 $15, T3 $47, T4 $100, T5 33%. • Multiple manufacturers to choose from • Multiple levels of technology to choose from Mail-Order Through CVS Caremark (2x copay for 90-day supply): • Hearing aid fittings at no charge,and more! T1 $0, T2 $0, T3 $94, T4 $200. Major Preferred Pharmacies: CVS, Big Y, Price Chopper, Arrow, HearingCareSolutions.com/carepartnersct Medicine Shoppe HCS Customer Service: 1-866-344-7756 1Services subject to $1,000 medical deductible prior to cost share. 2$0 for diagnostic colonoscopy. 3The plan is administered by Dominion Dental Services, Inc., which operates under the trade name Dominion National. For the HMO plans, services must be performed by providers in the Dominion PPO Network. PPO members may choose to receive treatment from a non-participating dentist but may pay higher costs for services and are responsible for any cost above the Maximum Allowable Charge (MAC) charged by the non-par- ticipating dentist. Broker use only. Confidential and proprietary. Not to be distributed or shared with Medicare beneficiaries. Distribution to any person or company is prohibited and may be grounds for contract termination. Plan and benefit information contained in this document is pending government approval and subject to change. Final 2021 plan and benefit information may be discussed with beneficiaries on or after October 1. Not intended for use in marketing materials for the general public. SilverSneakers is a registered trademark of Tivity Health, Inc. © 2020 Tivity Health, Inc. All rights reserved. H0342_2021_15_C H5273_2021_14_C.