Benefit & Cost-Share
|
CDPHP Basic Rx HMO
|
| Monthly Premium* |
$31 |
| Medical Deductible |
No deductible |
|
Primary Care Physician Office Visit Copayment |
$0 |
| Doctor On Demand |
$0 |
| Specialist Office Visit Copayment |
$45 |
| Routine Annual Physical Exam Copayment |
$0 |
| Over-the-counter Items |
$50/quarter |
Help at Home and Companionship
|
Up to 30 hours of companionship, transportation, help around the house, and technology assistance |
| Urgent Care Copayment |
$65 |
| Emergency Room Copayment1 |
$90 worldwide coverage |
| Ambulance |
$260 |
| Ambulatory Surgery Center |
$280 |
| Outpatient Hospital Services |
$330 |
| Inpatient Hospitalization |
Days 1-6: $335 per day |
| |
No copayment after day 6 |
| Skilled Nursing Facility Care |
Days 1-20: $0 per day |
| |
Days 21-100: $150 per day |
Delta Dental Provider:
Routine Cleanings/Restorative (per year) |
2 cleaning; $20 copay per exam
Restorative $60-$595
- Delta Dental Medicare Advantage Network for CDPHP® |
Non Delta Dental Provider:
Routine Cleaning/Restorative/Dentures |
$500 allowance |
Vision
- Annual Routine Eye Exam
- Frames/Lenses (per year)
(20% coinsurance for one pair after cataract surgery) |
$20
$125 allowance |
| Hearing Care Solutions Hearing Aid Benefit |
$599 or $899 |
| Meal Delivery Following Inpatient Stay |
14 meals provided |
| Diagnostic Tests and Lab Services2 |
$0 or $45 |
| X-rays |
$40 |
| Advanced Imaging Studies (CT, MRI, etc.) |
$140 |
| Part B Rx and Therapeutic Radiology |
20% coinsurance |
| CaféWell and Incentives |
Earn up to $175 |
| OOP Max |
$6,700 |
*You must continue to pay your Medicare Part B premium.
View the Basic Rx plan Evidence of Coverage (EOC) and Summary of Benefits (SOB) for all covered services.
Review your estimated prescription costs with this plan
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, 2023. 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.
Y_0019_22_16818 – last updated 10/01/2021