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CDPHP Vital Rx (PPO)

H5042 - 009 - 0
4.5 out of 5 stars (4.5 / 5)

CDPHP Vital Rx (PPO) is a Medicare Advantage Plan by CDPHP Medicare Advantage.

This page features plan details for 2025 CDPHP Vital Rx (PPO) H5042 – 009 – 0 available in Greater Capital Region of New York State.

Locations

CDPHP Vital Rx (PPO) is offered in the following locations.

Albany County, New York
Allegany County, New York
Broome County, New York

Click to see more locations

Plan Overview

CDPHP Vital Rx (PPO) offers the following coverage and cost-sharing.

Insurer:CDPHP Medicare Advantage
Health Plan Deductible:$0
MOOP:$10,100 In and Out-of-network
$6,750 In-network
$10,100 Out-of-network
Drugs Covered:Yes

Ready to sign up for CDPHP Vital Rx (PPO) ?

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 Vital Rx (PPO) has a monthly premium of $0.00. 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 $0.00 $ $
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 Vital Rx (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $300.00
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
$0.00$0.00

Initial Coverage Phase

After you pay your $300.00 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 Vital Rx (PPO) 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)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Implant Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Maxillofacial Prosthetics
    • Out-of-Network: No Coins – No Copay (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)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Orthodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

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

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $175 copay (Authorization Required, Referral Required)
  • Diagnostic tests and procedures
    • In-Network: 0-20% coinsurance (Authorization Required, Referral Required)
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)
  • Outpatient x-rays
    • In-Network: $10 copay (Authorization Required, Referral Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)
  • Outpatient x-rays
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)
  • Lab services
    • In-Network: $0-5 copay (Authorization Required, Referral Required)
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
  • Specialist
    • Out-of-Network: 40% coinsurance per visit (Authorization Required, Referral Required)
  • Primary
    • Out-of-Network: $50 copay per visit
  • Specialist
    • In-Network: $0-45 copay per visit (Authorization Required, Referral Required)

Emergency care/Urgent care

  • Emergency
    • $120 copay per visit (always covered)
  • Urgent care
    • $55 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $45 copay (Referral Required)
    • Out-of-Network: 40% coinsurance (Referral Required)
  • Routine foot care
    • Not covered

Ground ambulance

    • In-Network: $265 copay
    • Out-of-Network: $265 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • Out-of-Network: $599-899 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 40% coinsurance
  • Fitting/evaluation
    • In-Network: $0 copay
    • Out-of-Network: 40% coinsurance
  • Hearing aids
    • In-Network: $599-899 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $45 copay

Inpatient hospital coverage

    • In-Network: $500 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required, Referral Required)
    • Out-of-Network: 40% per stay (Authorization Required, Referral Required)

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

    • $10,100 In and Out-of-network
      $6,750 In-network
      $10,100 Out-of-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 25% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
    • In-Network: 25% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: $35 copay or 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 40% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit
    • Out-of-Network: 40% coinsurance (Referral Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay (Referral Required)
    • Out-of-Network: 40% coinsurance (Referral Required)
  • Outpatient group therapy visit
    • In-Network: $40 copay (Referral Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 40% coinsurance (Referral Required)
    • In-Network: $40 copay (Referral Required)
  • Inpatient hospital – psychiatric
    • In-Network: $455 per day for days 1 through 5
      $0 per day for days 6 through 90 (Referral Required)
    • Out-of-Network: 40% per stay (Referral Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay (Referral Required)
    • Out-of-Network: 40% coinsurance (Referral Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 40% coinsurance per visit (Authorization Required, Referral Required)
    • In-Network: $360 copay per visit (Authorization Required, Referral Required)

Preventive care

    • Out-of-Network: 40% coinsurance (Authorization Required)
    • In-Network: $0 copay (Authorization Required)

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $40 copay (Referral Required)
    • Out-of-Network: 40% coinsurance (Referral Required)
  • Occupational therapy visit
    • In-Network: $40 copay (Referral Required)
    • Out-of-Network: 40% coinsurance (Referral Required)

Skilled Nursing Facility

    • Out-of-Network: 40% per stay (Authorization Required, Referral Required)
    • In-Network: $0 per day for days 1 through 20
      $184 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

    • Out-of-Network: $0 copay (Authorization Required)
    • In-Network: $0 copay (Authorization Required)

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 40% coinsurance (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Routine eye exam
    • In-Network: $20 copay (Limits Apply)
  • Upgrades
    • Not covered
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for CDPHP Vital Rx (PPO) ?

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

Need more information on CDPHP Vital Rx (PPO)? See 2025 CDPHP Vital Rx (PPO) at MedicareAdvantageRX.com.

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