CDPHP Core (HMO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: CDPHP Medicare Advantage
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $0-$25 copay
Out-of-network: $0 copay
Emergency Room
$100 copay
Ambulance Coverage
In-network: $165 copay
Out-of-network: $165 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$25 copay
Out-of-network: $0-$25 copay
Lab services:
In-network: $0-$5 copay
Out-of-network: $0-$5 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $100 copay
Out-of-network: $100 copay
Outpatient x-rays:
In-network: $25 copay
Out-of-network: $25 copay
Hospital Services
Inpatient hospital coverage:
Tier 1
$260 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Outpatient hospital coverage:
In-network: $275 copay
Out-of-network: $275 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $25 copay
Out-of-network: $25 copay
Urgent Care Coverage
$100 copay
Skilled Nursing Facility (SNF)
Tier 1
$0 per day for days 1-20
$120 per day for days 21-100
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $25 copay
Out-of-network: $25 copay
Outpatient individual therapy with a psychiatrist:
In-network: $25 copay
Out-of-network: $25 copay
Outpatient group therapy visits:
In-network: $25 copay
Out-of-network: $25 copay
Outpatient individual therapy visit:
In-network: $25 copay
Out-of-network: $25 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0-$25 copay
Out-of-network: $0-$25 copay
Fitting/evaluation:
In-network: $0-$25 copay
Out-of-network: $0-$25 copay
Hearing aids - prescription:
In-network: $199-$499 copay
Out-of-network: $199-$499 copay
Additional Added Benefits
Plan Links
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