Complete Rx PPO
|
Monthly Premium*
$70
|
In-Network
|
Out-of-Network
|
Primary Care Physician
$0
|
Primary Care Physician
$40
|
Doctor on Demand
$0
|
Doctor on Demand
$0
|
Specialist Copayment
$40
|
Specialist Copayment
30%
|
Routine Annual Physical Exam Copayment
$0
|
Routine Annual Physical Exam Copayment
30%
|
Urgent Care Copayment
$55 worldwide coverage
|
Urgent Care Copayment
$55 worldwide coverage
|
Emergency Room Copayment1
$120 worldwide coverage
|
Emergency Room Copayment1
$120 worldwide coverage
|
Ambulance
$255
|
Ambulance
$255
|
Outpatient Surgery
$275-$325
|
Outpatient Surgery
30%
|
Physical Therapy
$40
|
Physical Therapy
$60
|
Inpatient Hospitalization
Days 1-6: $310 per day
|
Inpatient Hospitalization
30%
|
Dental Allowance on a prepaid Benefits Mastercard to use at any dentist in the U.S. for all dental services, routine cleaning/restorative/dentures (not to be used for teeth whitening):
$1,400
|
Vision: Annual Routine Eye Exam
$20
|
Vision: Annual Routine Eye Exam
30%
|
Frames/Lenses on a prepaid Benefits Mastercard (per year)
$225
|
Hearing Care Solutions Hearing Aid Benefit (per ear)
$599 or $899
|
Over-the-counter Benefit on a prepaid Benefits Mastercard
$50 / quarter
|
Over-the-counter Benefit on a prepaid Benefits Mastercard
Not available
|
Senior Fit Included
Yes
|
CDPHP Life Points® Rewards
Earn up to $125
|
Lab Services
$0 or $5
|
Lab Services
30%
|
X-rays
$5
|
X-rays
$40
|
Advanced Imaging Studies (CT, MRI, etc.)
$135
|
Advanced Imaging Studies (CT, MRI, etc.)
30%
|
OOP Max
$6,000
|
OOP Max (Combined)
$10,100
|
Plan Documents
Evidence of Coverage (EOC) & Summary of Benefits (SOB) Information
|
View a side-by-side comparison
Medicare Advantage Plan Options
Medicare Advantage Plan Options – Western NY
|