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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
- Annual Routine Eye Exam
- Frames/Lenses (per year)
(20% coinsurance for one pair after cataract surgery)

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.


  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, 2022. Limitations, copayments, and restrictions may apply.

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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 7/1/2021

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Medicare Hearing Care

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CDPHP best Medicare by US News

Best Insurance Companies for Medicare Advantage 2021, U.S. News & World Report