Benefit & Cost-Share
|
In-
Network
|
Out-of-Network
|
| Monthly Premium |
$0 |
| Medical Deductible |
$0 |
| Primary Care Physician Office Visit Copayment |
$0 |
$50 |
| Doctor On Demand |
$0 |
N/A |
| Special Office Visit Copayment |
$50 |
$60 |
| Routine Annual Physical Exam Copayment |
$0 |
40% |
| Urgent Care Copayment |
$65 |
$65 |
| Emergency Room Copayment |
$90 |
$90 |
| Ambulance |
$265 |
$265 |
| Ambulatory Surgery Center |
$345 |
40% |
| Outpatient Hospital Services |
$395 |
40% |
| Inpatient Hospitalization |
Days 1-4; $460
No copayment after day 4 |
40% |
| Skilled Nursing Facility Care |
$0 days 1-20
$184 days 21-100 |
40% |
| Dental-Routine Cleaning/Exam |
1 preventive cleaning per year
$20 copay per exam
$20 per bitewing
$30 per panoramic x-ray
$30 per full mouth x-ray |
N/A |
| Dental-Restorative |
Not available |
Vision
- Annual Routine Eye Exam
- Frames/Lenses (per year)
(20% coinsurance for one pair after cataract surgery)
|
$20
$50/2 years
|
40%
N/A
|
| Hearing Care Solutions Hearing Aid Benefit |
$599 or $899 |
N/A |
| Post-discharge Meals |
Covered |
Not Covered |
| Diagnostic Tests and Lab Services |
0% or 20% |
40% |
| X-rays |
$50 |
$50 |
| Advanced Imaging Studies (CT, MRI, etc) |
$220 |
40% |
| Part B Drugs and Radiation Therapy |
20% |
40% |
| CaféWell and Incentives |
$125 |
| OOP Max |
$7,500 |
$11,300 |
*You must continue to pay your Medicare Part B premium.
View the Vital Rx plan Evidence of Coverage (EOC) and Summary of Benefits (SOB) for all covered services.
Disclaimer:
-
Copayment waived if admitted to the hospital within 24 hours for the same diagnosis.
-
Copayment waived if services received at a preferred laboratory.
-
Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2022. Limitations, copayments, and restrictions may apply.
Out-of-network/non-contracted providers are under no obligation to treat Medicare Vital Rx members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
View HMO 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_16185 – last updated 01/26/2021