CDPHP Focus (PPO)

Cardiac and Pulmonary Rehabilitation Services

Additional Cardiac Rehabilitation Services

• Copay: $0.00

Additional Pulmonary Rehabilitation Services

• Copay: $40.00

Additional Intensive Cardiac Rehabilitation Services

• Copay: $0.00

Additional Supervised Exercise Therapy for Peripheral Artery Disease

• Copay: $0.00
• Authorization Required: Yes
• Referral Required: No

Durable Medical Equipment, Prosthetics/Orthotics, and Medical Supplies

Prosthetics/Medical Supplies

• Authorization Required: Yes
• Preferred Vendors: No

Prosthetics/Orthotics – Orthotic Devices

• Coinsurance: 20%

Prosthetics/Orthotics – Orthotic Devices

• Coinsurance: 20%

Medical Supplies – Medical/Surgical Supplies

• Coinsurance: 0% – 20%

Medical Supplies – Medical/Surgical Supplies

• Copay: $10.00
• Coinsurance: 20%
• Specified Manufacturers: Yes
• Limits Apply: Yes

Emergency and Urgent Care Services

Urgently Needed Services

• Copay: $90.00
• Enhanced Benefits: Worldwide Emergency Coverage; Worldwide Urgent Coverage; Worldwide Emergency Transportation
• Waivers if Admitted: Yes

Worldwide Emergency Transportation

• Copay: $90.00

Eye Exams and Eye Wear Services

Eye Exams

• Enhanced Benefits: Routine Eye Exams

Routine Eye Exams

• Limits Apply: No

Eyewear

• Copay: $40.00
• Authorization Required: No
• Referral Required: No
• Enhanced Benefits: Contact lenses; Eyeglasses (lenses and frames); Eyeglass lenses; Eyeglass frames

Contact Lenses

• Limits Apply: Yes

Eyeglasses (Lenses and Frames)

• Limits Apply: Yes

Eyeglass Lenses

• Limits Apply: Yes

Eyeglass Frames

• In-network: Both In-network and Out-of-network services
• Limits Apply: Yes

Health Care Professional Services

Opioid Treatment Program Services

• Copay: $0.00

Chiropractic Services

• Copay: $15.00
• Authorization Required: No
• Referral Required: Yes

Psychiatric Services – Inpatient Care

• Copay: $40.00

Psychiatric Services – Outpatient Care

• Copay: $40.00

PT and SP Services

• Copay: $40.00

Additional Telehealth Services

• Referral Required: No

Hearing Exams and Hearing Aids Services

Hearing Exams

• Enhanced Benefits: Routine Hearing Exams; Fitting/Evaluation for Hearing Aid

Routine Hearing Exams

• Limits Apply: No

Fitting/Evaluation for Hearing Aid

• Limits Apply: Yes

Hearing Aids

• Copay: $45.00
• Authorization Required: No
• Referral Required: No
• Enhanced Benefits: Hearing Aids (all types)

Hearing Aids (All Types)

• Copay: $599.00 – $899.00
• Limits Apply: No

Home Health Services

Home Health Services

• Copay: $0.00

Home Health Services

• Authorization Required: Yes
• Referral Required: No

Inpatient Hospital Acute Services

Inpatient Hospital-Acute

• Enhanced Benefits: Additional Days

Inpatient Acute Additional Days

• Limits Apply: Yes

Inpatient Hospital-Acute

• Authorization Required: Yes
• Referral Required: Yes
• Day Interval 1: $310.00 (Days 1 – 6)
• Day Interval 2: $0.00 (Days 7 – 90)

Inpatient Hospital Psychiatric Services

Inpatient Hospital-Psychiatric

• Enhanced Benefits: Additional Days

Inpatient Psychiatric Additional Days

• Limits Apply: Yes

Inpatient Hospital-Psychiatric

• Authorization Required: No
• Referral Required: Yes
• Day Interval 1: $300.00 (Days 1 – 5)
• Day Interval 2: $0.00 (Days 6 – 90)

Medicare Part B Prescription Drugs

Medicare Part B Drugs – Tier 2

• Coinsurance: 0% – 20%

Medicare Part B Drugs – Tier 3

• Copay: $35.00
• Coinsurance: 0% – 20%

Medicare Part B Drugs – Tier 1

• Copay: $35.00
• Authorization Required: Yes

Model Test

Physician Specialist Services

• Copay: $0.00

Out-of-Network Data for PPO Plans

Outpatient Clinical, Diagnostic, and Therapeutic Radiology Services

Outpatient Diagnostic Procedures/Tests

• Copay: $0.00 – $40.00

Outpatient Lab Services

• Copay: $0.00 – $5.00
• Authorization Required: Yes
• Referral Required: Yes

Outpatient Therapeutic Radiology

• Coinsurance: 20%

Outpatient Diagnostic Radiology

• Copay: $135.00

Outpatient X-Ray Services

• Copay: $35.00

Outpatient Hospital, ASC, Substance Abuse, and Cardiac Rehabilitation Services

Outpatient Hospital Services – General

• Copay: $325.00

Outpatient Hospital Services – Observation

• Copay: $325.00
• Authorization Required: Yes
• Referral Required: Yes

Outpatient Blood Services – Type 1

• Copay: $40.00

Outpatient Blood Services – Type 2

• Copay: $40.00
• Authorization Required: No
• Referral Required: No

Outpatient Blood Services

• Copay: $0.00

Partial Hospitalization Services

Partial Hospitalization

• Copay: $55.00
• Authorization Required: No
• Referral Required: Yes

Preventive Services (Health Education, Immunizations, Routine Physicals, Pap/Pelvic Exams)

Kidney Disease Education Services

• Authorization Required: Yes
• Referral Required: No

Other Medicare-covered Preventive Services

• Authorization Required: No

Other Defined Supplemental Benefits

• Enhanced Benefits: 14c1: Health Education;14c2: Nutritional/Dietary Benefit;14c3: Additional Sessions of Smoking and Tobacco Cessation Counseling;14c4: Fitness Benefit*;14c16: Weight Management Programs*;14c21: In-Home Support Services;

Nutritional/Dietary Benefit

• Limits Apply: Yes

In-Home Support Services

• Copay: $0.00
• Referral Required: Yes

Diabetes Self-Management Training – Level 1

• MOOP Amount: $0.00 (Every year)

Diabetes Self-Management Training – Level 2

• MOOP Amount: $0.00 (Every year)

Diabetes Self-Management Training – Level 5

• MOOP Amount: $0.00 (Every year)
• Authorization Required: No

Diabetes Self-Management Training – Level 3

• Authorization Required: No

Diabetes Self-Management Training – Level 4

• Authorization Required: No
• Referral Required: No

Renal Dialysis Services

Dialysis Services

• Coinsurance: 20%
• Authorization Required: No
• Referral Required: No

Skilled Nursing Facility (SNF) Services

SNF Medicare-covered stay

• Authorization Required: Yes
• Referral Required: Yes
• Day Interval 1: $0.00 (Days 1 – 20)
• Day Interval 2: $145.00 (Days 21 – 100)