Medicare Basic

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

$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



  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 10/01/2021

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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.

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