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Choice | Choice Rx



CDPHP Choice HMO and CDPHP Choice Rx HMO

Monthly Premium* With Part D: $128.80
Without Part D: $39.90
Medical Deductible No deductible
Enhanced Primary Care
Primary Care Physician Office Visit Copayment
Doctor on Demand $10
Specialist Office Visit Copayment $30
Routine Annual Physical Exam Copayment $0
Urgent Care Copayment $55
Emergency Room Copayment1 $90 Worldwide Coverage
Ambulance $165
Ambulatory Surgery Center $150
Outpatient Hospital Services $200
Inpatient Hospitalization Days 1-6: $260 per day
No copayment after day 6
Skilled Nursing Facility Care Days 1-20: $0 per day
Days 21-100: $120 per day
Dental-Routine Cleaning/Exam Unlimited reimbursement 2 preventive cleanings
Annual X-ray Unlimited reimbursement 2 preventive x-rays per year
- Annual Routine Eye Exam
- Frames/Lenses (per year)(20% coinsurance for one pair after cataract surgery)

Up to $125 every year
Diagnostic Tests and Lab Services2 $0 or $30
X-rays $30
Advanced Imaging Studies (CT, MRI, etc) $100
Part B Drugs and Radiation Therapy 20%
CaféWell and Incentives Earn up to $125
OOP Max $5,000

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


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View the Choice and Choice Rx 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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Best Insurance Companies for Medicare Advantage 2019, U.S. News & World Report