Medicare Basic

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:

  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, 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 1/17/2022

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Our hours are 8 a.m. – 8 p.m. seven days a week, October 1 – March 31. From April 1 to September 30, Monday – Friday, our hours are 8 a.m. to 8 p.m. A voice messaging service is used weekends, after-hours, and federal holidays. Calls will be returned within one business day.

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CDPHP best Medicare by US News - 2022


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