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Basic Rx

 

Benefit

CDPHP Basic Rx HMO

Monthly Premium* $29.50
Medical Deductible No deductible
Enhanced Primary Care
Primary Care Physician Office Visit Copayment
$10
$15
Doctor on Demand $15
Specialist Office Visit Copayment $45
Routine Annual Physical Exam Copayment $0
Urgent Care Copayment $65
Emergency Room Copayment1 $90 Worldwide Coverage
Ambulance $260
Ambulatory Surgery Center $280
Outpatient Hospital Services $330
Inpatient Hospitalization Days 1-5: $360 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 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)

$45
$75 allowance
Diagnostic Tests and Lab Services2 $0 or $45
X-rays $40
Advanced Imaging Studies (CT, MRI, etc) $140
Part B Rx and Therapeutic Radiology 20% coinsurance
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 Basic Rx 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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