CDPHP Basic RX (HMO)
H3388 - 013 - 0
(4.5 / 5)
CDPHP Basic RX (HMO) is a Medicare Advantage Plan by CDPHP Medicare Advantage.
This page features plan details for 2024 CDPHP Basic RX (HMO) H3388 – 013 – 0 available in Greater Capital Region of New York State.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
CDPHP Basic RX (HMO) is offered in the following locations.
Plan Overview
CDPHP Basic RX (HMO) offers the following coverage and cost-sharing.
| Insurer: | CDPHP Medicare Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,700 In-network |
| Drugs Covered: | Yes |
Ready to sign up for CDPHP Basic RX (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
CDPHP Basic RX (HMO) has a monthly premium of $31.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $31.00 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
CDPHP Basic RX (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $31.00 | $ |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $6.00 copay | $0.00 copay | $6.00 copay |
| 2 (Generic) | $0.00 copay | $20.00 copay | $0.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $45.00 copay | $47.00 copay | $45.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $97.00 copay | $97.00 copay | $97.00 copay | $97.00 copay |
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $18.00 copay | $0.00 copay | $18.00 copay |
| 2 (Generic) | $0.00 copay | $60.00 copay | $0.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $135.00 copay | $141.00 copay | $90.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $291.00 copay | $291.00 copay | $242.50 copay | $291.00 copay |
| 5 (Specialty Tier) |
Gap Coverage Phase
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
CDPHP Basic RX (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $6,700 In-network |
| No |
| In-network | No |
| $330 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0-35 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-35 copay (Authorization is required.) (Referral is required.) |
| Lab services | $0-5 copay (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $140 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $35 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $35 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Routine eye exam | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $30 copay (Authorization is not required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $30 copay (Authorization is not required.) (Referral is required.) |
| $260 copay (Not applicable.) (Not applicable.) |
| $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Foot exams and treatment | $35 copay (Authorization is not required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | $35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $315 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $315 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is not required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is not required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is not required.) (Referral is required.) |
| Outpatient group therapy visit | $35 copay (Authorization is not required.) (Referral is required.) |
| Outpatient individual therapy visit | $35 copay (Authorization is not required.) (Referral is required.) |
| $0 per day for days 1 through 20 $150 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for CDPHP Basic RX (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
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