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Overview of the Most Frequently Used Medical Services3

Benefit

$0 Medicare Rx

Monthly Premium*

$0

Medical Deductible

No deductible

Primary Care Physician Office Visit Copayment
Enhanced Primary Care

$15
$15

Specialist Office Visit Copayment

$50

Routine Annual Physical Exam Copayment

$0

Urgent Care Copayment

$65

Emergency Room Copayment1

$80

Ambulatory Surgery Center

$325 or 20%

Outpatient Hospital Services

$375 or 20%

Inpatient Hospitalization

Days 1-4: $425 per day
No copayment after day 4

Skilled Nursing Facility Care

Days 1-20: $0 per day
Days 21-100: $164.50 per day

Dental–Routine Cleaning/Exam

1 preventive cleaning per year;
$20 copay for annual exam;
$20 bitewing x-ray;
$30 panoramic or full mouth x-ray;
Must be a Delta Dental provider.

Vision
–Annual Routine Eye Exam
–Frames/Lenses (per year) (20% coinsurance for one pair after cataract surgery)

$60
Up to $50 every two years

Diagnostic Tests and Lab Services2

$0 or 20%

X-rays 

$50

Advanced Imaging Studies (CT, MRI, etc)4

$150

Part B Drugs and Radiation Therapy

20%

OOP Max

$6,700

*You must continue to pay your Medicare Part B premium.

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Plan Resources
Summary of Benefits
Y0019_18_1099 Accepted
Evidence of Coverage
Y0019_18_3984 File & Use [09052017]

1. Copayment waived if admitted to the hospital within 24 hours for the same diagnosis.
2. Copayment waived if services received at a preferred laboratory.
3. The benefit information provided herein is a brief summary, not a comprehensive description of available benefits. For more information, contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2019. Limitations, copayments, and restrictions may apply.
4. Prior authorization required.

 

CDPHP is an HMO with a Medicare contract. Enrollment in CDPHP Medicare Choices depends on contract renewal.

Y0019_18_4760 Approved Last Updated 11/10/2017

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1-888-248-6522 (TTY/TDD: 711).