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CDPHP Vital Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CDPHP Vital Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CDPHP Vital Rx (PPO) in 2025, please refer to our full plan details page.
CDPHP Vital Rx (PPO) is a PPO 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 Vital Rx (PPO) 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 Vital Rx (PPO).
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 Vital Rx (PPO), 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 $300.00 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 combined Maximum Out-Of-Pocket cost of $10100.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10100.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Vital Rx (PPO) plan has a $300 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance based on the drug tier and pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies and preferred mail order, and a $20 copay at standard pharmacies and standard mail order. For standard generic drugs, the copay is $47 at all pharmacies. Preferred brand drugs have a 40% coinsurance, and non-preferred drugs have a 29% coinsurance.
Additional Benefits
The CDPHP Vital Rx (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a copay, outpatient services, and emergency services. The plan also covers a range of services with copays, such as primary care, hearing, vision, and dental care. This plan provides additional benefits like ambulance services, home health services with no copay, and coverage for durable medical equipment. However, it's important to note that this plan does not cover certain services like cardiac rehabilitation, additional hours of care, and some other specialized services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $500 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you pay a $455 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services with the CDPHP Vital Rx (PPO) plan includes coverage for all outpatient hospital services and outpatient substance abuse services, both with varying copays depending on the specific service. Ambulatory Surgical Center (ASC) Services have a $335 copay. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the CDPHP Vital Rx (PPO) plan, and requires a doctor referral. The copay for this benefit is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the CDPHP Vital Rx (PPO) plan. This includes both ground and air ambulance services, each with a copay of $265. Transportation Services to plan-approved health-related locations are covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the CDPHP Vital Rx (PPO) plan. Emergency Services have a $120 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Services have a copay of $120 for Worldwide Emergency Coverage, $55 for Worldwide Urgent Coverage, and $265 for Worldwide Emergency Transportation.
Primary Care See details
The CDPHP Vital Rx (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $40 copay, physician specialist services with a $0-$45 copay, mental health specialty services with a $40 copay for individual and group sessions, and physical therapy and speech-language pathology services with a $40 copay. The plan also covers additional telehealth benefits with a $0-$45 copay and opioid treatment program services with no copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The CDPHP Vital Rx (PPO) plan covers preventive services, including Medicare-covered services with no copay. Weight management programs are covered up to a maximum of $100 per year. 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, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, or counseling services.
Hearing Services See details
Hearing Services includes coverage for hearing exams with a $45 copay, routine hearing exams with a copay between $0 and $45, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $599 and $899, while 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 coverage for eye exams, with a $45 copay, and routine eye exams with a $20 copay. Eyewear is covered with a combined maximum of $125 per year for both in and out-of-network services, while contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered. Upgrades are not covered.
Dental Services See details
The CDPHP Vital Rx (PPO) plan covers dental services, including Medicare dental services with a $45 copay. Other dental services are covered, with a maximum plan benefit of $725 per year, and include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the CDPHP Vital Rx (PPO) plan, and prior authorization is required. The plan includes a $35 copay for Medicare Part B Insulin Drugs, and coinsurance between 0-20% for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis Services are covered by the CDPHP Vital Rx (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the CDPHP Vital Rx (PPO) plan, with a 25% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies. Diabetic Supplies have a 0-20% coinsurance, and 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 under the CDPHP Vital Rx (PPO) plan. Diagnostic Procedures/Tests have a coinsurance of at most 20%, while Lab Services have no copay. Diagnostic Radiological Services have a copay of $175, and Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have a copay of $10.
Home Health Services See details
Home Health Services are covered by the CDPHP Vital Rx (PPO) 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 Vital Rx (PPO) 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 Vital Rx (PPO) plan, but require prior authorization and a doctor's referral. You will have 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 SNF stays are not covered.
Other Services See details
Other Services in the CDPHP Vital Rx (PPO) plan include acupuncture, with a $20 copay, and meal benefits. 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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