A non-government entity
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 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
CDPHP $0 Medicare Rx (HMO) is a HMO plan offered by Capital District Physicians' Health Plan, Inc. available for the 2026 plan year 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 2026.
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
Health deductible: information not available.
This plan has a $500.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6750.00 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 features an annual prescription drug deductible of $500. Members enjoy no copay for Tier 1 preferred generic drugs when using preferred pharmacies or preferred mail-order services. For Tier 2 generic drugs, copayments start as low as $7 for a one-month supply at preferred locations compared to $20 at standard pharmacies. Brand-name and specialty medications are subject to coinsurance rather than flat copayments under this plan. Tier 3 preferred brand drugs require 20% coinsurance, Tier 4 non-preferred drugs require 29% coinsurance, and Tier 5 specialty drugs carry a 27% coinsurance for a one-month supply. These coinsurance rates remain the same whether you use preferred or standard pharmacies and mail-order options.
Additional Benefits
The CDPHP $0 Medicare Rx (HMO) plan offers essential medical coverage with no copay or coinsurance for primary care doctor visits, preventive services, and home health care. Specialist visits require a copay ranging from no copay to $35, while emergency room visits carry a $125 copay with no coinsurance. For hospital care, inpatient stays require a daily copay of up to $460 for the first five days followed by no copay, while outpatient hospital services require a $365 copay. Supplemental care includes preventive and comprehensive dental services with no copay or coinsurance up to a $400 annual limit. Routine vision exams require a $20 copay, while routine hearing exams range from no copay to a $35 copay, with prescription hearing aids requiring copays between $599 and $899. Additionally, the plan covers unlimited round-trip transportation to plan-approved health locations with no copay or coinsurance.
Inpatient Hospital See details
Inpatient hospital care is covered under the CDPHP $0 Medicare Rx (HMO) plan with no coinsurance, requiring a daily copay of $460 for days 1 to 5 for acute stays and $450 for days 1 to 5 for psychiatric stays, followed by no copay for additional days. Prior authorization and referrals are required, and non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services covered by CDPHP $0 Medicare Rx (HMO) feature no coinsurance, with outpatient hospital services requiring a $365 copay and ambulatory surgical center services requiring a $315 copay. Observation services carry a $330 daily copay, outpatient substance abuse services have a $35 copay, and outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
CDPHP $0 Medicare Rx (HMO) covers partial hospitalization services with a $105.00 copay and no coinsurance. A referral is required for some of these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the CDPHP $0 Medicare Rx (HMO) plan, with ground and air ambulance services requiring a $265 copay and no coinsurance. Transportation services are partially covered, offering unlimited round trips to plan-approved health-related locations with no copay or coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
CDPHP $0 Medicare Rx (HMO) covers emergency services with a $125 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $50 copay, both featuring no coinsurance. Worldwide emergency, urgent, and emergency transportation services are also covered with no coinsurance and copays of $125, $50, and $265, respectively.
Primary Care See details
Primary care benefits under the CDPHP $0 Medicare Rx (HMO) plan feature no copay and no coinsurance for primary care physician visits, while specialist visits and mental health services require a $0 to $35 copay with no coinsurance. Physical, occupational, and speech therapy services have a $30 copay and no coinsurance, but routine chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered by CDPHP $0 Medicare Rx (HMO), with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and diabetes self-management training. While select supplemental benefits like weight management and fitness are included, other services such as in-home safety assessments, personal emergency response systems, and medical nutrition therapy are not covered.
Hearing Services See details
Hearing services are partially covered by CDPHP $0 Medicare Rx (HMO), with routine hearing exams and fitting evaluations requiring a $0 to $35 copay and no coinsurance. Prescription hearing aids are covered with copays ranging from $599 to $899 and no coinsurance, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription aids are not covered.
Vision Services See details
Vision services are partially covered by the CDPHP $0 Medicare Rx (HMO) plan, which offers routine eye exams for a $20 copay and no coinsurance, and other covered exams for a $35 copay and no coinsurance. Eyewear is covered with no copay (plus a 20% coinsurance for contact lenses) up to a $200 annual limit, but other eye exam services and upgrades are not covered.
Dental Services See details
CDPHP $0 Medicare Rx (HMO) covers Medicare-covered dental services with a $35 copay and no coinsurance. Other preventive and comprehensive dental services, such as cleanings, exams, and fillings, are covered with no copay and no coinsurance up to a maximum benefit of $400 every year.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the CDPHP $0 Medicare Rx (HMO) plan with prior authorization, featuring a $35 copay and no coinsurance for Part B insulin. Other covered Part B drugs require a $35 copay and 0% to 20% coinsurance, while chemotherapy and radiation drugs require a copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the CDPHP $0 Medicare Rx (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by CDPHP $0 Medicare Rx (HMO), featuring no copay and a 25% coinsurance for durable medical equipment, prosthetics, and medical supplies. Diabetic supplies require a $5 copay and no coinsurance, while diabetic therapeutic shoes or inserts have a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
CDPHP $0 Medicare Rx (HMO) covers diagnostic and radiological services, which require prior authorization and referrals. Lab services feature no copay, diagnostic procedures require a copay with no coinsurance, and outpatient x-rays incur a $10 copay plus coinsurance. Diagnostic radiological services require a minimum $195 copay, while therapeutic radiological services require a copay and 20% coinsurance.
Home Health Services See details
Home health services are covered under the CDPHP $0 Medicare Rx (HMO) plan with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are not covered under the CDPHP $0 Medicare Rx (HMO) plan. This includes cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) services, which are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by CDPHP $0 Medicare Rx (HMO) with no coinsurance, featuring no copay for days 1 through 20 and a $215 daily copay for days 21 through 100. Prior authorization and a referral are required for this benefit, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
Other services are partially covered by the CDPHP $0 Medicare Rx (HMO) plan, which includes acupuncture for a $20 copay and no coinsurance up to 10 treatments annually, and meal benefits with no copay and no coinsurance for qualifying medical conditions. Over-the-counter (OTC) items are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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