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Overview of the Most Frequently Used Medical Services3



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

$80 Worldwide Coverage

Ambulatory Surgery Center


Outpatient Hospital Services


Inpatient Hospitalization

Days 1-5: $335 per day
No copayment after day 5

Skilled Nursing Facility Care

Days 1-20: $0 per day
Days 21-100: $150 per day

Dental–Routine Cleaning/Exam

2 preventive cleanings per year;
$20 copay for annual exam;
$20 bitewing x-ray;
$30 panoramic or full mouth x-ray;
Must use Delta Dental provider.

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

$75 allowance

Diagnostic Tests and Lab Services2

$0 or $45



Advanced Imaging Studies (CT, MRI, etc)4


Part B Rx and Therapeutic Radiology

20% coinsurance



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

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CDPHP Basic Rx (HMO) Plan Resources
Summary of Benefits
Y0019_18_1099 Accepted
Annual Notice of Changes and Evidence of Coverage (Basic Rx)
Y0019_18_3323 File & Use [08222017]

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 2/22/2018

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