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2017 Medicare Advantage HMO

Overview of the Most Frequently Used Medical Services3



Monthly Premium*



No deductible

Primary Care Physician Office Visit Copayment


Specialist Office Visit Copayment


Routine Annual Physical Exam Copayment


Urgent Care Copayment


Emergency Room Copayment1

$75 Worldwide Coverage

Ambulatory Surgery Center


Outpatient Hospital Services


Inpatient Hospitalization

Days 1-6: $255 per day
No copayment after day 6

Skilled Nursing Facility Care

Days 1-20: $0 per day
Days 21-100: $130 per day

Dental–Routine Cleaning/Exam

2 preventive office visits, up to $100 total, per year

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

$50 allowance

Diagnostic Tests and Lab Services2

$0 to $40



Advanced Imaging Studies (CT, MRI, etc)4


Part B Drugs and Therapeutic Radiology




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

CDPHP Value Rx (HMO) Plan Resources
Summary of Benefits
Y0019_17_0471 Accepted
Annual Notice of Changes and Evidence of Coverage
Y0019_17_0349 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