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FlexPOS Platinum Alternative

94815CT0050001
Platinum
POS

FlexPOS Platinum Alternative is a Platinum POS plan by ConnectiCare Insurance Company, Inc..

Locations

FlexPOS Platinum Alternative is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of FlexPOS Platinum Alternative 94815CT0050001.
Insurer: ConnectiCare Insurance Company, Inc.
Network Type: POS
Metal Type: Platinum
HSA Eligible?: No
Plan ID: 94815CT0050001

Cost-Sharing Overview

FlexPOS Platinum Alternative offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for FlexPOS Platinum Alternative?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

FlexPOS Platinum Alternative offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Diabetes
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what FlexPOS Platinum Alternative covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Medically Necessary Coverage applies
National Network: Yes

Additional Benefits and Cost-Sharing

FlexPOS Platinum Alternative includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No $200 copayment when done in a Free-standing location
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per 2 Years
Early Intervention Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Post-Mastectomy Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Visit(s) per Year Covered up to age 26Substantially Equal
Wound Care for Individuals with Epidermolysis Bullosa
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No90 Days per Year
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30-day supply retail or 90 day supply mail order. Insulin and non-insulin drugs are covered up to a max of $25 for each 30 day supply.
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered up to age 26Substantially Equal
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Accidental Ingestion of a Controlled Drug
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year Limit includes PT, ST and OT.
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No10 Hours per Lifetime If needed carrier may develop explanations pertinent in defining the benefit attributes. AHCT disagrees the limit is per life time. The limit per the document is up to 10 hrs initial training and up to 8 additional hrs under other circumstances.
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Year Covered up to age 26Substantially Equal
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30-day supply mail order
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Diabetes Care Management
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Diabetes Devices & Diabetic Ketoacidosis Devices are covered up to $100 per 30-day supply.Additional EHB Benefit
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No No cost when services are provided by Teladoc
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inherited Metabolic Disorder – PKU
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year Limit is combined for PT, ST and OT.
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment of Medical Complications of Alcoholism
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bone Marrow Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Some PT and surgery covered.
Routine Eye Exam (Adult)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Year Not EHB
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered up to age 26Substantially Equal
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Visit(s) per Year
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No100 Visit(s) per Year OON is subject to a $50 deductible
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Mammography Ultrasound
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Deductible is waived when services are rendered at a freestanding facility
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Not EHB
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No3 Procedure(s) per Lifetime Not EHB
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Newborn child of participant covered for the first 61 days following birth; after, must be signed up. Newborn grandchild covered for 61 days if mother is enrolled daughter of participant; no mention of eligibility if the father is the son of the participant.
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30-day supply retail or 90 day supply mail order. Insulin and non-insulin drugs are covered up to a max of $25 for each 30 day supply.
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bones/Joints
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Acupuncture
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes When used for pain management only
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Developmental Needs of Children & Youth with Cancer
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No A wig prescribed by an oncologist for a Member suffering hair loss as a result of chemotherapy or radiation therapy is covered without Pre-Authorization up to one wig per year.
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Covered up to age 26Substantially Equal
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Medically necessary services only. Covered up to age 26.Substantially Equal
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year Limit includes PT, ST and OT.
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered if the Member has a life expectancy of six months or less and if the care is Pre-Authorized or Pre-Certified.
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Visit(s) per Year
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30-day supply retail or 90 day supply mail order. Insulin and non-insulin drugs are covered up to a max of $25 for each 30 day supply.

Free Preventive Services

There is no copayment or coinsurance for any of the following FlexPOS Platinum Alternative preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for FlexPOS Platinum Alternative?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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