** Cost ** |
Premium and Other Important Information |
$50.5 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$5 000 out-of-pocket limit. |
All plan services included. |
$5 000 out-of-pocket limit. |
All plan services included. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
Referral required for network hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Extra Benefits ** |
Prescription Drugs |
$15 copay for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
$15 copay for Part B drugs out-of-network. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.cdphp.com/medicare on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service).
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
Some drugs have quantity limits. |
Your provider must get prior authorization from CDPHP Core Rx (PPO) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and CDPHP Core Rx (PPO) approves the exception you will pay Tier 4: Generic and Non-Preferred Brand Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$8 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
$95 copay for a one-month (30-day) supply of drugs in this tier |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
$12 copay for a three-month (90-day) supply of drugs in this tier |
$24 copay for a three-month (90-day) supply of drugs in this tier |
$135 copay for a three-month (90-day) supply of drugs in this tier |
$285 copay for a three-month (90-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (31-day) supply of drugs in this tier |
$8 copay for a one-month (31-day) supply of drugs in this tier |
$45 copay for a one-month (31-day) supply of drugs in this tier |
$95 copay for a one-month (31-day) supply of drugs in this tier |
33% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$8 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
$95 copay for a one-month (30-day) supply of drugs in this tier |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
$8 copay for a three-month (90-day) supply of drugs in this tier |
$16 copay for a three-month (90-day) supply of drugs in this tier |
$90 copay for a three-month (90-day) supply of drugs in this tier |
$237.50 copay for a three-month (90-day) supply of drugs in this tier |
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from CDPHP Core Rx (PPO). |
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$8 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
$95 copay for a one-month (30-day) supply of drugs in this tier |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
Physical Exams |
When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests. |
Vision Services |
20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 to $35 copay for up to 1 routine eye exam(s) every year |
$0 to $35 copay for eye exams. |
20% of the cost for eye wear. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
up to 2 oral exam(s) every year |
up to 2 cleaning(s) every year |
up to 2 fluoride treatment(s) every year |
up to 2 dental x-ray(s) every year |
$0 copay for preventive dental benefits. |
$0 copay for comprehensive dental benefits. |
$100 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
** Important Information ** |
Premium and Other Important Information |
$50.5 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$5 000 out-of-pocket limit. |
All plan services included. |
$5 000 out-of-pocket limit. |
All plan services included. |
Doctor and Hospital Choice |
Referral required for network hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
No limit to the number of days covered by the plan each benefit period. |
For Medicare-covered hospital stays: |
Days 1 - 5: $275 copay per day |
Days 6 - 90: $0 copay per day |
$0 copay for additional hospital days |
For hospital stays: |
Days 1 - 5: $375 copay per day |
Days 6 and beyond: $0 copay per day |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
For Medicare-covered hospital stays: |
Days 1 - 5: $275 copay per day |
Days 6 - 90: $0 copay per day |
$0 copay for additional hospital days |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
For hospital stays: |
Days 1 - 5: $375 copay per day |
Days 6 and beyond: $0 copay per day |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
Days 1 - 20: $35 copay per day |
Days 21 - 100: $90 copay per day |
For each SNF stay: |
Days 1 - 20: $35 copay per SNF day |
Days 21 - 100: $90 copay per SNF day |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits. |
$0 copay for home health visits. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
$35 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each specialist visit for Medicare-covered benefits. |
$35 copay for each primary care doctor visit. |
$35 copay for each specialist visit. |
Chiropractic Services |
$35 copay for each Medicare-covered visit. |
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. |
$35 copay for chiropractic benefits. |
Podiatry Services |
$35 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
$35 copay for podiatry benefits. |
Outpatient Mental Health Care |
$35 copay for each Medicare-covered individual or group therapy visit. |
$35 copay for Mental Health benefits. |
$35 copay for Mental Health benefits with a psychiatrist. |
Outpatient Substance Abuse Care |
$35 copay for Medicare-covered individual or group visits. |
$35 copay for outpatient substance abuse benefits. |
Outpatient Hospital Services |
$250 copay for each Medicare-covered ambulatory surgical center visit. |
$250 copay for each Medicare-covered outpatient hospital facility visit. |
$250 copay for ambulatory surgical center benefits. |
$250 copay for outpatient hospital facility benefits. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits. |
Worldwide coverage. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
$35 copay for Medicare-covered Occupational Therapy visits. |
$35 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$35 copay for Medicare-covered Cardiac Rehab services. |
$35 copay for Occupational Therapy benefits. |
$35 copay for Physical and/or Speech and Language Therapy visits. |
$35 copay for Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
20% of the cost for durable medical equipment. |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
20% of the cost for prosthetic devices. |
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies |
$0 copay for Diabetes self-monitoring training. |
$0 copay for Nutrition Therapy for Diabetes. |
20% of the cost for Diabetes supplies. |
$0 copay for Diabetes self-monitoring training. |
$0 copay for Nutrition Therapy for Diabetes. |
20% of the cost for Diabetes supplies. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay for Medicare-covered bone mass measurement |
$0 copay for Medicare-covered bone mass measurement. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
$0 copay for colorectal screenings. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
No referral needed for Flu and pneumonia vaccines. |
$0 copay for immunizations. |
Pap Smears and Pelvic Exams |
$0 copay for Medicare-covered pap smears and pelvic exams |
up to 1 additional pap smear(s) and pelvic exam(s) every two years |
$0 copay for pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
$0 copay for - Medicare-covered prostate cancer screening
|
$0 copay for prostate cancer screening. |
** Additional Benefits ** |
Dialysis |
$25 copay for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease |
$35 copay for renal dialysis. |
$0 copay for Nutrition Therapy for End-Stage Renal Disease. |
Prescription Drugs |
$15 copay for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
$15 copay for Part B drugs out-of-network. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.cdphp.com/medicare on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service).
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
Some drugs have quantity limits. |
Your provider must get prior authorization from CDPHP Core Rx (PPO) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and CDPHP Core Rx (PPO) approves the exception you will pay Tier 4: Generic and Non-Preferred Brand Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$8 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
$95 copay for a one-month (30-day) supply of drugs in this tier |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
$12 copay for a three-month (90-day) supply of drugs in this tier |
$24 copay for a three-month (90-day) supply of drugs in this tier |
$135 copay for a three-month (90-day) supply of drugs in this tier |
$285 copay for a three-month (90-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (31-day) supply of drugs in this tier |
$8 copay for a one-month (31-day) supply of drugs in this tier |
$45 copay for a one-month (31-day) supply of drugs in this tier |
$95 copay for a one-month (31-day) supply of drugs in this tier |
33% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$8 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
$95 copay for a one-month (30-day) supply of drugs in this tier |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
$8 copay for a three-month (90-day) supply of drugs in this tier |
$16 copay for a three-month (90-day) supply of drugs in this tier |
$90 copay for a three-month (90-day) supply of drugs in this tier |
$237.50 copay for a three-month (90-day) supply of drugs in this tier |
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from CDPHP Core Rx (PPO). |
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Generic and Preferred Brand Drugs |
Tier 4: Generic and Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$8 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
$95 copay for a one-month (30-day) supply of drugs in this tier |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
up to 2 oral exam(s) every year |
up to 2 cleaning(s) every year |
up to 2 fluoride treatment(s) every year |
up to 2 dental x-ray(s) every year |
$0 copay for preventive dental benefits. |
$0 copay for comprehensive dental benefits. |
$100 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
Hearing Services |
Hearing aids not covered. |
$35 copay for Medicare-covered diagnostic hearing exams |
$35 copay for up to 1 routine hearing test(s) every year |
$35 copay for hearing exams. |
Vision Services |
20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 to $35 copay for up to 1 routine eye exam(s) every year |
$0 to $35 copay for eye exams. |
20% of the cost for eye wear. |
Physical Exams |
When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Nutritional Training |
Additional Smoking Cessation |
Health Club Membership/Fitness Classes |
Nursing Hotline |
Other Wellness Benefits |
Copays may apply for these benefits. |
$0 copay for each Medicare-covered smoking cessation counseling session. |
$0 copay for each Medicare-covered HIV screening. |
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. |
$0 to $35 copay for Health and Wellness services. |
Transportation |
Authorization rules may apply. |
$0 copay for each round trip to plan-approved location. |
$0 copay for transportation. |
Acupuncture |
This plan does not cover Acupuncture. |