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2017 Medicare Advantage HMO

Overview of the Most Frequently Used Medical Services3

Benefit

CDPHP Basic Rx HMO

Monthly Premium*

$36

Deductible

No deductible

Primary Care Physician Office Visit Copayment

$15

Specialist Office Visit Copayment

$50

Routine Annual Physical Exam Copayment

$0

Urgent Care Copayment

$65

Emergency Room Copayment1

$75 Worldwide Coverage

Ambulatory Surgery Center

$280

Outpatient Hospital Services

$330

Inpatient Hospitalization

Days 1-5: $360 per day
No copayment after day 5

Skilled Nursing Facility Care

Days 1-20: $0 per day
Days 21-100: $164.50 per day

Dental–Routine Cleaning/Exam

1 preventive office visit up to $75 per year, total

Vision
–Annual Routine Eye Exam
–Frames/Lenses (per year)
(20% coinsurance for one pair after cataract surgery)

$50
$50 allowance

Diagnostic Tests and Lab Services2

$0 to $50

X-rays 

$50

Advanced Imaging Studies (CT, MRI, etc)4

$140

Part B Rx and Therapeutic Radiology

20% coinsurance

OOP Max

$6,700

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

CDPHP Basic Rx (HMO) Plan Resources
Summary of Benefits
Y0019_17_0471 Accepted
Annual Notice of Changes and Evidence of Coverage (Basic Rx)
Y0019_17_0347 File & Use [08262016]

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, 2018. Limitations, copayments, and restrictions may apply.
4. Prior authorization required.

CDPHP is an HMO with a Medicare contract. Enrollment in CDPHP Medicare Choices depends on contract renewal.

Y0019_17_1486 Approved Last Updated 03/31/2017