Medicare Value

Benefit & Cost-Share

CDPHP Value Rx HMO

Monthly Premium* $60.80
Medical Deductible No deductible
Primary Care Physician Office Visit Copayment $0
Doctor On Demand $0
Specialist Office Visit Copayment $35
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 $60
Emergency Room Copayment1 $90 worldwide coverage
Ambulance $250
Ambulatory Surgery Center $200
Outpatient Hospital Services $300
Inpatient Hospitalization Days 1-6: $295 per day
No copayment after day 6
Skilled Nursing Facility Care Days 1-20: $0 per day
Days 21-100: $140 per day
Delta Dental Provider:
Routine Cleanings/Restorative (per year)
2 cleaning; $10 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
$150 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 $35
X-rays $35
Advanced Imaging Studies (CT, MRI, etc) $130
Part B Drugs and Therapeutic Radiology 20%
CaféWell and Incentives Earn up to $175
OOP Max $5,800

*You must continue to pay your Medicare Part B premium.

 

View the Value Rx plan Evidence of Coverage (EOC) and Summary of Benefits (SOB) for all covered services.

  Review your estimated prescription costs with this plan

 


Disclaimer:

  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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