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:
Copayment waived if admitted to the hospital within 24 hours for the same diagnosis.
Copayment waived if services received at a preferred laboratory.
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