ConnectiCare Choice Plan 1 (HMO-POS)
Available to residents of Tolland County, CT for 2026. Contract H3528, plan 016, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Tolland County
- Plan website
- Browse the ConnectiCare Choice Plan 1 (HMO-POS) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $162.00 |
|---|---|
| — medical (Part C) part | $124.50 |
| — drug (Part D) part | $37.50? |
| Monthly premium with full Extra Help (LIS) | $128.40?drug (Part D) part $3.90; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $4,150.00? |
| Drug deductible | $200.00Tier 1 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO-POS? |
| Contract / plan | H3528-016-0 |
| Offered by | ConnectiCare |
| Parent organization | Molina Healthcare, Inc. |
| Formulary drugs | 3,522 |
| Formulary exception tier | 4? |
| Pharmacy search | www.connecticare.com/medicare |
| Member services | (833)310-1182TTY 711 |
CMS star ratings
- Overall
- 3.5 out of 5 stars for Overall
- Health plan (Part C)
- 3.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H3528 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay |
| Other health care professional | $0–$30 copay(authorization required) |
| Additional telehealth services | $0–$30 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $25 copay(authorization required) |
| Lab services | $0–$10 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$200 copay(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $35 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $140 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $0 copay · $50,000 plan limit |
| Worldwide urgent care | $0 copay · $50,000 plan limit |
| Worldwide emergency transportation | $0 copay |
| Hospital care | |
| Inpatient hospital stay | $345 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient hospital services | $0–$200 copay(authorization required) |
| Outpatient observation | $295 copay |
| Ambulatory surgical center | $0–$100 copay(authorization required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $214 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $30 copay |
| Physical therapy and speech-language therapy | $30 copay |
| Cardiac rehabilitation | $30 copay(authorization required) |
| Pulmonary rehabilitation | $20 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $2,545 per stay(authorization required) |
| Outpatient mental health, individual session | $30 copay(authorization required) |
| Outpatient mental health, group session | $30 copay(authorization required) |
| Psychiatrist, individual session | $30 copay(authorization required) |
| Psychiatrist, group session | $30 copay(authorization required) |
| Partial hospitalization | $55 copay(authorization required) |
| Intensive outpatient program | $55 copay(authorization required) |
| Outpatient substance use, individual session | $30 copay(authorization required) |
| Outpatient substance use, group session | $30 copay(authorization required) |
| Opioid treatment program | $30 copay(authorization required) |
| Ambulance and transportation | |
| Ground ambulance | $295 copay(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 10%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $20 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $30 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $30 copay |
| Oral exams | Not covered |
| Cleanings | Not covered |
| Fluoride treatment | Not covered |
| Dental x-rays | Not covered |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | Optional supplemental benefit (extra premium) |
| Endodontics (root canals) | Optional supplemental benefit (extra premium) |
| Periodontics (gum disease) | Optional supplemental benefit (extra premium) |
| Dentures and other removable prosthodontics | Optional supplemental benefit (extra premium) |
| Maxillofacial prosthetics | Optional supplemental benefit (extra premium) |
| Implants | Optional supplemental benefit (extra premium) |
| Bridges and other fixed prosthodontics | Optional supplemental benefit (extra premium) |
| Oral and maxillofacial surgery | Optional supplemental benefit (extra premium) |
| Orthodontics | Optional supplemental benefit (extra premium) |
| Adjunctive general services | Optional supplemental benefit (extra premium) |
| Vision? | |
| Eye exam (Medicare-covered) | $30 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay |
| Contact lenses | Not covered |
| Eyeglasses (frames and lenses) | Not covered |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $30 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | Not covered |
| Hearing aids (all types) | Not covered |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Not covered |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | $0 copay |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | $0 copay |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $1.00 |
| Tier 2 | $15.00 |
| Tier 3 | 25% |
| Tier 4 | 27% |
| Tier 5 | 30% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $1.00 | $1.00 | $1.00 | $2.00 | $2.00 | $2.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $1.00 | $1.00 | $1.00 | $2.00 | $2.00 | $2.00 |
| Tier 2: Generic | $15.00 | $15.00 | $15.00 | $30.00 | $30.00 | $30.00 |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 27% | 27% | 27% | 27% | 27% | 27% |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 7 other CT counties
Benefits in plain text
ConnectiCare Choice Plan 1 (HMO-POS) (H3528-016-0) is a 2026 HMO-POS Medicare Advantage plan offered by ConnectiCare, available to residents of Tolland County, CT.
The monthly premium is $162.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $128.40.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $4,150.00.
The drug deductible is $200.00. Tier 1 and 6 exempt.
The plan's formulary lists 3,522 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $1.00; tier 2: $15.00; tier 3: 25%; tier 4: 27%; tier 5: 30%; tier 6: $0.00.
CMS gives the plan's contract (H3528) an overall rating of 3.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.