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Vital Rx

Medicare Vital Plan

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Monthly Premium $0
Medical Deductible $0
Enhanced Primary Care $15 No coverage
Primary Care Physician Office Visit Copayment $15 $50
Doctor On Demand $15 N/A
Special Office Visit Copayment $50 $60
Routine Annual Physical Exam Copayment $0 40%
Urgent Care Copayment $65 $65
Emergency Room Copayment $90 $90
Ambulance $265 $265
Ambulatory Surgery Center $330 40%
Outpatient Hospital Services $380 40%
Inpatient Hospitalization Days 1-4; $450
No copayment after day 4
Skilled Nursing Facility Care $0 days 1-20
$172 days 21-100
Dental-Routine Cleaning/Exam 1 preventive cleaning per year
$20 copay per exam
$20 per bitewing
$30 per panoramic x-ray
$30 per full mouth x-ray
Dental-Restorative Not available
- Annual Routine Eye Exam
- Frames/Lenses (per year)
(20% coinsurance for one pair after cataract surgery)

$50/2 years

Hearing Care Solutions Hearing Aid Benefit $599 or $899 N/A
Diagnostic Tests and Lab Services 0% or 20% 40%
X-rays $50 $50
Advanced Imaging Studies (CT, MRI, etc) $200 40%
Part B Drugs and Radiation Therapy 20% 40%
CaféWell and Incentives $125
OOP Max $6,700 $10,000

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


View the Vital 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, 2021. Limitations, copayments, and restrictions may apply.

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

Y0019_20_10926 - last updated 6/17/2020

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