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Basic Rx Option

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Benefit & Cost-Share


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
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
Over-the-counter Items $50/quarter
Dental-Routine Cleaning/Exam 2 preventive cleanings 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)

$75 allowance
Post-discharge Meals Covered
Hearing Care Solutions Hearing Aid Benefit $599 or $899
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.



  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.

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 7/1/2021

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