CDPHP Clear Rx (HMO)
Available to residents of Saratoga County, NY for 2026. Contract H3388, plan 020, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Saratoga County
- Plan website
- Browse the CDPHP Clear Rx (HMO) formulary
New for 2026. This plan has no 2025 predecessor in the CMS crosswalk.
Plan details
| Monthly premium (Part C + D) | $100.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $100.00? |
| Monthly premium with full Extra Help (LIS) | $41.20? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $6,400.00? |
| Drug deductible | $250.00Tier 1, 2 and 3 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H3388-020-0 |
| Offered by | CDPHP Medicare Advantage |
| Parent organization | Lifetime Healthcare, Inc. |
| Formulary drugs | 4,068 |
| Formulary exception tier | 4? |
| Pharmacy search | findadoc.cdphp.com/ |
| Member services | (888)519-4455TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H3388 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0–$30 copay(authorization and referral required) |
| Other health care professional | $30 copay(authorization and referral required) |
| Additional telehealth services | $0–$30 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay(authorization required) |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay(referral required) |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0–$30 copay(authorization and referral required) |
| Lab services | $0–$5 copay(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $130 copay(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | $5 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $115 copay |
| Urgent care | $50 copay |
| Worldwide emergency coverage | $115 copay |
| Worldwide urgent care | $50 copay |
| Worldwide emergency transportation | $225 copay |
| Hospital care | |
| Inpatient hospital stay | $375 per day for days 1–6; $0 per day for days 7–90(authorization and referral required) |
| Outpatient hospital services | $350 copay(authorization and referral required) |
| Outpatient observation | $375 copay |
| Ambulatory surgical center | $275 copay(authorization and referral required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $200 per day for days 21–100(authorization and referral required) |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $30 copay(referral required) |
| Physical therapy and speech-language therapy | $30 copay(referral required) |
| Cardiac rehabilitation | $0 copay |
| Pulmonary rehabilitation | $0 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $375 per day for days 1–6; $0 per day for days 7–90(referral required) |
| Outpatient mental health, individual session | $30 copay(referral required) |
| Outpatient mental health, group session | $30 copay(referral required) |
| Psychiatrist, individual session | $30 copay(referral required) |
| Psychiatrist, group session | $30 copay(referral required) |
| Partial hospitalization | $105 copay(referral required) |
| Intensive outpatient program | $105 copay |
| Outpatient substance use, individual session | $30 copay |
| Outpatient substance use, group session | $30 copay |
| Opioid treatment program | $0 copay |
| Ambulance and transportation | |
| Ground ambulance | $225 copay(authorization required) |
| Air ambulance | $225 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(authorization required) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $5 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | 50% coinsurance(limits apply) |
| Foot exams and treatment (Medicare-covered) | $30 copay(referral required) |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $30 copay |
| Preventive dental plan limit | $900 plan limit every year |
| Oral exams | $0 copay |
| Cleanings | $0 copay |
| Fluoride treatment | $0 copay |
| Dental x-rays | $0 copay |
| Other diagnostic dental services | $0 copay |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | $0 copay |
| Endodontics (root canals) | $0 copay |
| Periodontics (gum disease) | $0 copay |
| Dentures and other removable prosthodontics | $0 copay |
| Maxillofacial prosthetics | $0 copay |
| Implants | $0 copay |
| Bridges and other fixed prosthodontics | $0 copay |
| Oral and maxillofacial surgery | $0 copay |
| Orthodontics | $0 copay |
| Adjunctive general services | $0 copay |
| Vision? | |
| Eye exam (Medicare-covered) | $30 copay |
| Routine eye exam | $20 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(limits apply) |
| Eyewear plan limit | $250 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $30 copay |
| Routine hearing exam | $0–$30 copay(limits apply) |
| Hearing aid fitting and evaluation | $0–$30 copay |
| Hearing aids (all types) | $599–$899 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | $35 copay; 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Not covered |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay(limits apply) |
| Health education | $0 copay(limits apply) |
| Nutritional / dietary benefit | $0 copay(limits apply) |
| Extra smoking and tobacco cessation counseling | $0 copay(limits apply) |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | $0 copay(limits apply) |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | $0 copay(limits apply) |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $2.00 |
| Tier 3 | 20% |
| Tier 4 | 37% |
| Tier 5 | 30% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $2.00 | $18.00 | $2.00 | $6.00 | $54.00 | $4.00 |
| Tier 3: Preferred Brand | 20% | 20% | 20% | 20% | 20% | 20% |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $2.00 | $18.00 | $2.00 | $6.00 | $54.00 | $4.00 |
| Tier 3: Preferred Brand | 20% | 20% | 20% | 20% | 20% | 20% |
| Tier 4: Non-Preferred Drug | 37% | 37% | 37% | 37% | 37% | 37% |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 17 other NY counties
Benefits in plain text
CDPHP Clear Rx (HMO) (H3388-020-0) is a 2026 HMO Medicare Advantage plan offered by CDPHP Medicare Advantage, available to residents of Saratoga County, NY.
The monthly premium is $100.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $41.20.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $6,400.00.
The drug deductible is $250.00. Tier 1, 2 and 3 exempt.
The plan's formulary lists 4,068 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $2.00; tier 3: 20%; tier 4: 37%; tier 5: 30%.
CMS gives the plan's contract (H3388) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.