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.
-
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, 2022. Limitations, copayments, and restrictions may apply.
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_13605 - last updated 10/01/2020