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$0 Medicare Plan

 

Benefit

$0 Medicare Rx

Monthly Premium*

$0

Medical Deductible

No deductible

Enhanced Primary Care

Primary Care Physician Office Visit Copayment

$15

$15

Specialist Office Visit Copayment

$50

Routine Annual Physical Exam Copayment

$0

Urgent Care Copayment

$65

Emergency Room Copayment1

$80

Ambulance

$265

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.

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

Disclaimers:

  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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