Benefit
|
$0 Medicare Rx HMO
|
| Monthly Premium* |
$0 |
| Medical Deductible |
No deductible |
Enhanced Primary Care
Primary Care Physician Office Visit Copayment |
$10
$15 |
| Doctor On Demand |
$15 |
| 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 |
$300 |
| Outpatient Hospital Services |
$350 |
| Inpatient Hospitalization |
Days 1-5: $350 per day |
| |
No copayment after day 5 |
| Skilled Nursing Facility Care |
Days 1-20: $0 per day |
| |
Days 21-100: $172 per day |
| 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) |
$50
Up to $50 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.) |
$175 |
| Part B Drugs and Radiation Therapy |
20% |
| CaféWell and Incentives |
Earn up to $175 |
| OOP Max |
$6,700 |
*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, 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