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$0 Medicare Plan



$0 Medicare Rx

Monthly Premium*


Medical Deductible

No deductible

Enhanced Primary Care

Primary Care Physician Office Visit Copayment



Specialist Office Visit Copayment


Routine Annual Physical Exam Copayment


Urgent Care Copayment


Emergency Room Copayment1




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 per bitewing x-ray;
$30 per panoramic or full mouth x-ray;
Must be a Delta Dental Medicare Advantage for CDPHP network provider.

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

Up to $50 every two years

Diagnostic Tests and Lab Services2

$0 or 20%



Advanced Imaging Studies (CT, MRI, etc)4


Part B Drugs and Radiation Therapy




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


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View the $0 plan Evidence of Coverage (EOC) and Summary of Benefits (SOB) for all covered services.


  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_8268 Approved - last updated 08/20/2018


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