Benefit & Cost-Share
|
$0 Medicare Rx HMO
|
Monthly Premium* |
$0 |
Medical Deductible |
No deductible |
Primary Care Physician Office Visit Copayment |
$0 |
Doctor On Demand |
$0 |
Over-the-counter benefit |
$50 per quarter |
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 |
$315 |
Outpatient Hospital Services |
$365 |
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: $184 per day |
Meal Delivery Following Inpatient Stay: Covered |
Covered |
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. |
Dental-Restorative |
Available |
Vision
- Annual Routine Eye Exam
- Frames/Lenses (per year)
(20% coinsurance for one pair after cataract surgery) |
$20
Up to $75 every two years |
Hearing Care Solutions Hearing Aid Benefit |
$599 or $899 |
Diagnostic Tests and Lab Services2 |
$0 or 20% |
X-rays |
$50 |
Advanced Imaging Studies (CT, MRI, etc.) |
$195 |
Part B Drugs and Radiation Therapy |
20% |
CaféWell and Incentives |
Earn up to $175 |
OOP Max |
$7,500 |
*You must continue to pay your Medicare Part B premium.
View $0 Medicare 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, 2022. Limitations, copayments, and restrictions may apply.
View PPO Plan Options»
CDPHP Medicare Advantage is an HMO and PPO plan with a Medicare contract. Enrollment in CDPHP Medicare Advantage depends on contract renewal.
Y0019_21_13605 - last updated 10/29/2020