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CDPHP Choice Rx (HMO)

H3388 - 002 - 0
4.5 out of 5 stars (4.5 / 5)

CDPHP Choice Rx (HMO) is a Medicare Advantage Plan by CDPHP Medicare Advantage.

This page features plan details for 2025 CDPHP Choice Rx (HMO) H3388 – 002 – 0 available in Greater Capital Region of New York State.

Locations

CDPHP Choice Rx (HMO) is offered in the following locations.

Albany County, New York
Broome County, New York
Chenango County, New York

Click to see more locations

Plan Overview

CDPHP Choice Rx (HMO) offers the following coverage and cost-sharing.

Insurer:CDPHP Medicare Advantage
Health Plan Deductible:$0
MOOP:$6,000 In-network
Drugs Covered:Yes

Ready to sign up for CDPHP Choice 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 Choice Rx (HMO) has a monthly premium of $126.00. 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
$185.00 $0.00 $126.00 $ $
Please Note:
  • 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 Choice Rx (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

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 DLIS Full
$126.00$59.90

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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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 Choice Rx (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply, Referral Required)
  • Implant Services
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Maxillofacial Prosthetics
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay (Limits Apply, Referral Required)
  • Orthodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay (Limits Apply, Referral Required)
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Limits Apply, Referral Required)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Limits Apply, Referral Required)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply, Referral Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay (Limits Apply)
  • Fluoride Treatment
    • In-Network: No Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – No Copay (Limits Apply)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • $100 copay (Authorization Required, Referral Required)
  • Diagnostic tests and procedures
    • $0-25 copay (Authorization Required, Referral Required)
  • Lab services
    • $0-5 copay (Authorization Required, Referral Required)
  • Outpatient x-rays
    • $5 copay (Authorization Required, Referral Required)

Doctor visits

  • Specialist
    • $0-25 copay per visit (Authorization Required, Referral Required)
  • Primary
    • $0 copay

Emergency care/Urgent care

  • Urgent care
    • $50 copay per visit (always covered)
  • Emergency
    • $100 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • $25 copay (Referral Required)

Ground ambulance

    • $185 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • $199-499 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • $25 copay
  • Hearing aids OTC
    • Not covered
  • Fitting/evaluation
    • $0 copay

Inpatient hospital coverage

    • $260 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $6,000 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • $10 copay or 0-20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • $35 copay or 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • $260 per day for days 1 through 6
      $0 per day for days 7 through 90 (Referral Required)
  • Outpatient group therapy visit with a psychiatrist
    • $25 copay (Referral Required)
  • Outpatient individual therapy visit
    • $25 copay (Referral Required)
  • Outpatient group therapy visit
    • $25 copay (Referral Required)
  • Outpatient individual therapy visit with a psychiatrist
    • $25 copay (Referral Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $200 copay per visit (Authorization Required, Referral Required)

Preventive care

    • $0 copay (Authorization Required)

Rehabilitation services

  • Occupational therapy visit
    • $25 copay (Referral Required)
  • Physical therapy and speech and language therapy visit
    • $25 copay (Referral Required)

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $120 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

    • $0 copay (Authorization Required)

Vision

  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply)
  • Contact lenses
    • $0 copay (Limits Apply)
  • Eyeglass lenses
    • $0 copay (Limits Apply)
  • Eyeglass frames
    • $0 copay (Limits Apply)
  • Other
    • Not covered
  • Routine eye exam
    • $0 copay (Limits Apply)
  • Upgrades
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for CDPHP Choice 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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