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CDPHP Choice Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CDPHP Choice Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CDPHP Choice Rx (HMO) in 2025, please refer to our full plan details page.
CDPHP Choice Rx (HMO) is a HMO plan offered by Capital District Physicians' Health Plan, Inc. available for enrollment in 2025 to people living in Greater Capital Region of New York State. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that CDPHP Choice Rx (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about CDPHP Choice Rx (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For CDPHP Choice Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $126.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The CDPHP Choice Rx (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay different copays or coinsurance amounts depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. This plan offers an "Enhanced Alternative" drug benefit. Please note that you may pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The CDPHP Choice Rx (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $260 copay for the first six days, then no copay for the rest of the stay. Outpatient services and emergency services have copays ranging from $25 to $200, while primary care visits have no copay. Preventive, vision, and dental services are covered, with no copays for routine exams and cleanings. The plan also includes coverage for hearing aids, medical equipment, and home health services. Other benefits include coverage for ambulance, partial hospitalization, and other services.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $260 copay for days 1-6 and no copay for days 7-90; additional days are covered with no copay, while non-Medicare-covered stays and upgrades are not covered. Prior authorization and a doctor referral are required.
Outpatient Services See details
Outpatient Services, covered by the CDPHP Choice Rx (HMO) plan, include outpatient hospital services with a $200 copay, observation services with a $260 copay, ambulatory surgical center services with a $150 copay, outpatient substance abuse services with a $25 copay for individual and group sessions, and outpatient blood services with no copay. Prior authorization and a doctor referral are required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered by the CDPHP Choice Rx (HMO) plan, with a required doctor referral. The copay for this benefit is $100.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by CDPHP Choice Rx (HMO), with prior authorization required. Ground and air ambulance services have a copay of $185.00, and transportation services to a plan-approved health-related location are covered. Transportation services to any other health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered. Emergency Services and Worldwide Emergency Coverage have a $100 copay, Urgently Needed Services has a $50 copay, Worldwide Urgent Coverage has a $50 copay, and Worldwide Emergency Transportation has a $185 copay.
Primary Care See details
Primary Care Physician Services have no copay, Chiropractic Services have a $20 copay, Occupational Therapy Services have a $25 copay, Physician Specialist Services have a $0-$25 copay, Mental Health Specialty Services have a $25 copay, Physical Therapy and Speech-Language Pathology Services have a $25 copay, Additional Telehealth Benefits have a $0-$25 copay, and Opioid Treatment Program Services have no copay; however, Routine Chiropractic Care is not covered, and Podiatry Services are not covered.
Preventive Services See details
The CDPHP Choice Rx (HMO) plan covers preventive services, including Medicare-covered services with prior authorization, and additional services like annual physical exams, health education, weight management programs, nutritional/dietary benefits, in-home support services, additional smoking cessation sessions, and fitness benefits. Some services, like in-home safety assessments, are not covered, and Weight Management Programs have a maximum benefit coverage amount of $100 per year.
Hearing Services See details
Hearing Services include hearing exams, with a $25 copay, and prescription hearing aids, covered up to 2 per year with a copay between $199 and $499. Routine hearing exams and fitting/evaluation for hearing aids are also covered. OTC hearing aids are not covered, and prescription hearing aids for the inner, outer, and over the ear are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay, and eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames with 20% coinsurance, up to a combined maximum of $300 per year. Routine eye exams have no copay. Upgrades are not covered.
Dental Services See details
The CDPHP Choice Rx (HMO) plan covers dental services, including oral exams, dental x-rays, and other diagnostic services with no copay. The plan also covers cleaning and fluoride treatments with no copay and other preventive services with no copay. The plan offers up to $1,850 per year for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay, while the coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the CDPHP Choice Rx (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, are covered. DME has a 20% coinsurance, while Prosthetics/Medical Supplies and Diabetic Therapeutic Shoes/Inserts also have a 20% coinsurance. Diabetic Supplies have a $10 copay and a coinsurance between 0% and 20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $25, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at least $100, and Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have a $5 copay.
Home Health Services See details
Home Health Services are covered by the CDPHP Choice Rx (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the CDPHP Choice Rx (HMO) plan. This includes Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CDPHP Choice Rx (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, but there is a $120 copay for days 21-100, and additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The CDPHP Choice Rx (HMO) plan covers acupuncture with 50% coinsurance, and up to 10 treatments per year. Over-the-counter items are covered with a maximum benefit of $75 every three months, and meal benefits are also covered for chronic illnesses and medical conditions. However, several other services are not covered, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and Home and Community Based Services.
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