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CDPHP Value Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CDPHP Value Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CDPHP Value Rx (HMO) in 2025, please refer to our full plan details page.
CDPHP Value 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 Value 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 Value 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 Value Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $62.00. 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 $6400.00 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 Value Rx (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have no copay when using a preferred pharmacy or mail order, but a $18 copay at a standard pharmacy. For preferred brand drugs and non-preferred drugs, you will pay 39% and 33% coinsurance, respectively. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The CDPHP Value Rx (HMO) plan offers a range of benefits with varying costs. You'll find no copay for primary care physician visits, home health services, and days 7-90 of inpatient hospital and psychiatric stays. Many other services require a copay, such as inpatient hospital stays (days 1-6), outpatient services, emergency services, and specialist visits, with some services like hearing exams and vision services having copays as well. The plan also includes coverage for ambulance, dental, and home infusion services, with copays or coinsurance applying. Preventive services, hearing exams, and vision services are covered, along with diagnostic and radiological services. The plan offers additional benefits like acupuncture, over-the-counter items, and a meal benefit, but excludes some services such as cardiac rehabilitation, and additional hours of care services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. For Inpatient Hospital-Acute, you will pay a $295 copay for days 1-6, and no copay for days 7-90; for Inpatient Hospital Psychiatric, you will pay a $275 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $300 copay, Observation Services with a $295 copay, Ambulatory Surgical Center (ASC) Services with a $200 copay, and Outpatient Substance Abuse Services with a $30 copay for individual and group sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the CDPHP Value Rx (HMO) plan with a doctor referral required. The copay for this benefit is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by CDPHP Value Rx (HMO). Ground and air ambulance services have a $225 copay, with no coinsurance. Transportation services to a plan-approved health-related location are covered, but transportation services to any other health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $110 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $225 copay.
Primary Care See details
Under the CDPHP Value Rx (HMO) plan, primary care physician services have no copay, while chiropractic services require a $15 copay, but routine care is not covered. Occupational therapy services have a $30 copay, and physician specialist services have a copay between $0 and $30. Mental health and psychiatric individual and group sessions have a $30 copay, and physical therapy and speech-language pathology services have a $30 copay. Additional telehealth benefits have a copay between $0 and $30, and opioid treatment program services have no copay.
Preventive Services See details
Preventive Services are covered, including annual physical exams and other services such as glaucoma screenings, diabetes self-management training, and barium enemas. Some services, such as in-home safety assessments, personal emergency response systems, and counseling services, are not covered.
Hearing Services See details
Hearing exams are covered with a $30 copay, and routine hearing exams and fitting/evaluation for hearing aids are included. Prescription hearing aids (all types) are covered with a copay between $599 and $899, but prescription hearing aids for inner, outer, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The CDPHP Value Rx (HMO) plan covers vision services, including routine eye exams for a $20 copay and eyewear with 20% coinsurance. Eyewear upgrades are not covered.
Dental Services See details
The CDPHP Value Rx (HMO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatments. There is a $30 copay for Medicare dental services, and the plan has a maximum benefit of $1650 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs have a coinsurance between 0% and 20%, and Other Medicare Part B Drugs have a copay of $35 and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the CDPHP Value Rx (HMO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance, and Prosthetics/Medical Supplies with a 20% coinsurance and Diabetic Equipment. Diabetic Supplies have a $10 copay and 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance; Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay between $0 and $30, Lab Services with no copay, Diagnostic Radiological Services with a copay of at least $130, Therapeutic Radiological Services with at least 20% coinsurance, and Outpatient X-Ray Services with a $5 copay. All services require prior authorization and a doctor's referral.
Home Health Services See details
Home Health Services are covered by the CDPHP Value 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 Value Rx (HMO) plan, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is no copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CDPHP Value Rx (HMO) plan, with prior authorization and a doctor's referral required. For days 1-20, there is no copay, and for days 21-100, there is a $140 copay.
Other Services See details
The CDPHP Value Rx (HMO) plan covers acupuncture with a 50% coinsurance, and up to 10 treatments per year. Over-the-counter (OTC) items are covered with a maximum benefit of $75 every three months, and a meal benefit is also covered. However, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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