Complete Rx (PPO)

H5042 - 014 - 0

(4.5 / 5)

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

This page features plan details for 2025 Complete Rx (PPO) H5042 – 014 – 0 available in Greater Capital Region of New York State.

Locations

Complete 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

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

Insurer:	CDPHP Medicare Advantage
Health Plan Deductible:	No
MOOP:	$10,100.00 combined
Drugs Covered:	Yes

Ready to sign up for Complete 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

Complete Rx (PPO) has a monthly premium of $70.00. 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	$70.00	$	$

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

Complete Rx (PPO) 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 D	LIS Full
$70.00	$0.00

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 $2,000.00. 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		$5.00 Copay		$5.00 Copay
2) Generic		$19.00 Copay		$19.00 Copay
3) Preferred Brand	$44.00 Copay	$47.00 Copay	$44.00 Copay	$47.00 Copay
4) Non-Preferred Drug	45.00% Coinsurance	45.00% Coinsurance	45.00% Coinsurance	45.00% Coinsurance
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$10.00 Copay		$10.00 Copay
2) Generic		$38.00 Copay		$38.00 Copay
3) Preferred Brand	$88.00 Copay	$94.00 Copay	$88.00 Copay	$94.00 Copay
4) Non-Preferred Drug	45.00% Coinsurance	45.00% Coinsurance	45.00% Coinsurance	45.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$15.00 Copay		$15.00 Copay
2) Generic		$57.00 Copay		$57.00 Copay
3) Preferred Brand	$132.00 Copay	$141.00 Copay	$88.00 Copay	$141.00 Copay
4) Non-Preferred Drug	45.00% Coinsurance	45.00% Coinsurance	45.00% Coinsurance	45.00% Coinsurance
5) Specialty Tier

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

Complete Rx (PPO) also provides the following benefits.

Cardiac and Pulmonary Rehabilitation Services

Additional Pulmonary Rehabilitation Services

Coinsurance: 30%

Additional Cardiac Rehabilitation Services

Copay: $0.00

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

Diabetic Supplies and Services

MOOP Amount: $300.00 (Other, Describe)

Prosthetics/Medical Supplies

Authorization Required: Yes
Preferred Vendors: No

Prosthetics/Orthotics – Orthotic Devices

Coinsurance: 25%

Prosthetics/Orthotics – Orthotic Devices

Coinsurance: 25%

Medical Supplies – Medical/Surgical Supplies

Coinsurance: 0% – 20%

Medical Supplies – Medical/Surgical Supplies

Copay: $10.00
Coinsurance: 25%
Specified Manufacturers: Yes
Limits Apply: Yes

Emergency and Urgent Care Services

Urgently Needed Services

Copay: $120.00
Enhanced Benefits: Worldwide Emergency Coverage; Worldwide Urgent Coverage; Worldwide Emergency Transportation
Waivers if Admitted: Yes

Worldwide Emergency Transportation

Copay: $120.00

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: $40.00
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

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: $310.00 (Days 1 – 6)
Day Interval 2: $0.00 (Days 7 – 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

Coinsurance: 0% – 20%

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: $5.00

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

Outpatient Hospital Services – General

Copay: $325.00

Outpatient Hospital Services – Observation

Copay: $310.00
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: $105.00
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)

Ready to sign up for Complete 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