| Choice HMO and Choice Rx HMO1 |
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Monthly Premium2
Choice: $39.90*
Choice Rx: $124
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Primary Care Physician Office Visit Copayment
$0
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Doctor on Demand
$0
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Specialist Office Visit Copayment
$25
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Routine Annual Physical Exam Copayment
$0
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Urgent Care Copayment
$45 worldwide coverage
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Emergency Room Copayment3
$90 worldwide coverage
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Ambulance
$165
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Outpatient Surgery
$150-$200
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Physical Therapy
$25
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Inpatient Hospitalization
Days 1-6: $260 per day
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Dental Allowance on a prepaid Benefits Mastercard to use at any dentist for all dental services,
routine cleaning/restorative/dentures (not to be used for teeth whitening):
$1,500 reimbursement
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Vision: Annual Routine Eye Exam
$0
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Frames/Lenses (per year)
$250 reimbursement
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Hearing Care Solutions Hearing Aid Benefit
$199 or $499
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Over-the-counter Benefit
$75 / quarter
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Senior Fit Included
Yes
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CDPHP Life Points® Rewards
Earn up to $175
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Lab Services
$0 or $5
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X-rays
$25
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Advanced Imaging Studies (CT, MRI, etc.)
$100
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OOP Max
$6,100
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Plan Documents
Evidence of Coverage (EOC) & Summary of Benefits (SOB) Information
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View a side-by-side comparison
Medicare Advantage Plan Options
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