CDPHP $0 Medicare Rx (HMO)

Medicare Plan Details (2022 Plan)


Monthly Premium

 

by CDPHP Medicare Advantage
Additional Coverage
HearingVisionDental
Overall Government Star Rating
 5.0
out of 5 stars

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Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$7,500 In-network
No
Yes
Yes
Yes

Doctor Services

$0 copay
$0-40 copay per visit

Tests, labs, & imaging

0-20% coinsurance
0-20% coinsurance
$195 copay
$40 copay
$90 copay per visit (always covered)
$65 copay per visit (always covered)

Hospital Services

$360 per day for days 1 through 5
$0 per day for days 6 through 90
$365 copay per visit

Skilled nursing facility

$0 per day for days 1 through 20
$184 per day for days 21 through 100

Preventive services

$0 copay

Ambulance

$265 copay

Therapy services

$40 copay
$40 copay

Mental health services

$40 copay
$40 copay
$40 copay
$40 copay

Opioid treatment services

Covered

Other services

20% coinsurance per item
20% coinsurance per item
0-20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$3.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$3.95 copay or 5% (whichever costs more)

Brand-name drugs :
$9.85 copay or 5% (whichever costs more)

Generic$17.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier27%

Part B Drugs

20% coinsurance
$35 copay or 20% coinsurance

Hearing

$40 copay
$0 copay
$599-899 copay

Preventive Dental

Covered under office visit
Covered under office visit
Not covered
$20-30 copay

Comprehensive dental

$0 copay
$0 copay
$60-595 copay
$0 copay
$0 copay
$0 copay
$0 copay

Vision

$20 copay
$0 copay
$0 copay
$0 copay
$0 copay
Not covered

Other benefits

Limited coverage
Limited coverage
Limited coverage
Not covered
Limited coverage
Limited coverage
Limited coverage
 5
 5
 4
 5
 5
 5
 5
 5
 5
 4
 4

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