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Overview of the Most Frequently Used Medical Services3


$0 Medicare Rx

Monthly Premium*


Medical Deductible

No deductible

Primary Care Physician Office Visit Copayment
Enhanced Primary Care


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 bitewing x-ray;
$30 panoramic or full mouth x-ray;
Must be a Delta Dental 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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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_3446 Approved Last Updated 4/30/2018

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1-888-248-6522 (TTY/TDD: 711).