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Choice/Choice Rx

Overview of the Most Frequently Used Medical Services3

Benefit

CDPHP Choice (HMO) and CDPHP Choice Rx (HMO)

Monthly Premium*

With Part D: $122
Without Part D: $34.90

Medical Deductible

No deductible

Primary Care Physician Office Visit Copayment
Enhanced Primary Care

$10
$0

Specialist Office Visit Copayment

$30

Routine Annual Physical Exam Copayment

$0

Urgent Care Copayment

$55

Emergency Room Copayment1

$80 Worldwide

Ambulatory Surgery Center

$150

Outpatient Hospital Services

$200

Inpatient Hospitalization

Days 1-6: $225 per day
No copayment after day 6

Skilled Nursing Facility Care

Days 1-20: $0 per day
Days 21-100: $110 per day

Dental–Routine Cleaning/Exam

2 office visits per year;
$0 copay

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

$30 
Up to $125 every year

Diagnostic Tests and Lab Services2

$0 or $30

X-rays 

$30

Advanced Imaging Studies (CT, MRI, etc)4

$100

Part B Drugs and Radiation Therapy

20%

OOP Max

$4,800

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

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CDPHP Choice and Choice Rx (HMO) Plan Resources
Summary of Benefits
Y0019_18_1099 Accepted
Annual Notice of Changes and Evidence of Coverage (Choice)
Y0019_18_3319 File & Use [08222017]
Annual Notice of Changes and Evidence of Coverage (Choice Rx)
Y0019_18_3322 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 12/29/2017

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