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CDPHP $0 Medicare Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CDPHP $0 Medicare Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CDPHP $0 Medicare Rx (HMO) in 2025, please refer to our full plan details page.
CDPHP $0 Medicare 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 $0 Medicare 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 $0 Medicare 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 $0 Medicare Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 a $250.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 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 $0 Medicare Rx (HMO) plan has a $250 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies or through mail order. For standard generic drugs, the copay is $47, regardless of the pharmacy. Brand name drugs have a 39% coinsurance, and non-preferred drugs have a 30% coinsurance.
Additional Benefits
The CDPHP $0 Medicare Rx (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $450 copay for the first 5 days, then no copay for days 6-90. Outpatient services, including doctor visits and specialist visits, have copays, while primary care visits have no copay. This plan also includes coverage for preventive services, hearing, vision, and dental care, with associated copays or coinsurance. Other covered services include ambulance, emergency care, home health services, and skilled nursing facility stays, which have no copay for the first 20 days.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both of which require prior authorization and a doctor's referral. For the first 5 days of an inpatient stay, the copay is $450, and there is no copay for days 6-90.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $365 copay, Observation Services with a $330 copay, Ambulatory Surgical Center (ASC) Services with a $315 copay, Individual and Group Sessions for Outpatient Substance Abuse with a copay between $35.00 and $35.00, and Outpatient Blood Services with no copay. Prior authorization and a doctor referral may be required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered under the CDPHP $0 Medicare Rx (HMO) plan, with a $105 copay. A doctor referral is required to receive this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the CDPHP $0 Medicare Rx (HMO) plan. Ground and Air Ambulance Services have a copay of $265, 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 by the CDPHP $0 Medicare Rx (HMO) plan. Emergency Services have a $120 copay, and Urgently Needed Services have a $55 copay, while Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $265 copay.
Primary Care See details
Primary Care Physician services have no copay, Chiropractic services have a $15 copay, and Occupational Therapy Services have a $30 copay. Specialist services and telehealth services have a copay between $0 and $35, and mental health and psychiatric services have a $35 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $30 copay, and opioid treatment program services have no copay. Routine Chiropractic care and podiatry services are not covered.
Preventive Services See details
The "CDPHP $0 Medicare Rx (HMO)" plan covers preventive services including Medicare-covered zero dollar preventive services, annual physical exams, and additional preventive services. The plan does not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, alternative therapies, therapeutic massage, adult day health services, home-based palliative care, support for caregivers of enrollees, and counseling services.
Hearing Services See details
Hearing Services include hearing exams, which have a $35 copay, and prescription hearing aids. Prescription Hearing Aids (all types) are covered with a copay between $599 and $899, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $35 copay, and routine eye exams with a $20 copay. Eyewear is covered with 20% coinsurance, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered. Upgrades are not covered.
Dental Services See details
The CDPHP $0 Medicare Rx (HMO) plan covers Medicare Dental Services with a $35 copay, and other dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics. There is a maximum plan benefit of $750 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 Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the CDPHP $0 Medicare Rx (HMO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 25% coinsurance, Prosthetics/Medical Supplies with 25% coinsurance, and Diabetic Equipment. Diabetic Supplies have between 0% and 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services. Diagnostic Procedures/Tests have a coinsurance of at most 20%, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $195, while Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the CDPHP $0 Medicare 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 $0 Medicare Rx (HMO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CDPHP $0 Medicare Rx (HMO) plan, with prior authorization and a doctor referral required. There is no copay for days 1-20, and a $184 copay for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture, meal benefits, and other services. Acupuncture has a $20 copay per visit, up to 10 treatments per year. Over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, 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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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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