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$0 Plan



$0 Medicare Rx HMO

Monthly Premium* $0
Medical Deductible No deductible
Enhanced Primary Care
Primary Care Physician Office Visit Copayment
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.
- 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%
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.


  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 07/30/2019

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CDPHP best Medicare by US News

Best Insurance Companies for Medicare Advantage 2019, U.S. News & World Report