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$0 Plan

 

Benefit

$0 Medicare Rx HMO

Monthly Premium* $0
Medical Deductible No deductible
Enhanced Primary Care
Primary Care Physician Office Visit Copayment
$15
$15
Doctor on Demand $15
Specialist Office Visit Copayment $50
Routine Annual Physical Exam Copayment $0
Urgent Care Copayment $65
Emergency Room Copayment1 $90 Worldwide Coverage
Ambulance $265
Ambulatory Surgery Center $325 or 20% (whichever is less)
Outpatient Hospital Services $375 or 20% (whichever is less)
Inpatient Hospitalization Days 1-4: $450 per day
  No copayment after day 4
Skilled Nursing Facility Care Days 1-20: $0 per day
  Days 21-100: $172 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 use 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)

$50
Up to $50 every two years
Diagnostic Tests and Lab Services2 $0 or 20%
X-rays $50
Advanced Imaging Studies (CT, MRI, etc) $175
Part B Drugs and Radiation Therapy 20%
CaféWell and Incentives Earn up to $125
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, 2020. Limitations, copayments, and restrictions may apply.

CDPHP Medicare Advantage is an HMO plan with a Medicare contract. Enrollment in CDPHP Medicare Advantage depends on contract renewal.

Y0019_19_7087 - last updated 12/05/2018

 

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