A non-government entity
CDPHP Focus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CDPHP Focus (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CDPHP Focus (PPO) in 2025, please refer to our full plan details page.
CDPHP Focus (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 Focus (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about CDPHP Focus (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 Focus (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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $9550.00 (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 $9550.00 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:
Sign up for CDPHP Focus (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
Prescription drugs are not covered by CDPHP Focus (PPO).
Additional Benefits
The CDPHP Focus (PPO) plan offers a range of benefits, including inpatient and outpatient hospital services with varying copays. Emergency, urgent, and worldwide emergency services are covered with copays ranging from $55 to $255. You will also have access to primary care, preventive, hearing, vision, and dental services, with some services having no copay and others with copays typically ranging from $15 to $45, and a yearly eyewear benefit. Additional benefits include ambulance and transportation services, home health services with no copay, and skilled nursing facility care with a copay after 20 days. The plan also covers home infusion services and dialysis services, and offers coverage for medical equipment with coinsurance. Other covered services are acupuncture, over-the-counter items, and a meal benefit, while some services like cardiac rehabilitation are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits for the CDPHP Focus (PPO) plan cover Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with prior authorization and doctor referrals required. For Inpatient Hospital-Acute, you pay a $310 copay for days 1-6 and no copay for days 7-90; for Inpatient Hospital Psychiatric, you pay a $300 copay for days 1-5 and no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $325 copay, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with a $250 copay, Individual and Group Sessions for Outpatient Substance Abuse with a copay between $40 and $40, 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 Focus (PPO) plan with a $55 copay, and a doctor referral is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including services not usually covered by Medicare, are covered by the CDPHP Focus (PPO) plan. Ground and Air Ambulance Services have a copay of $255, with no coinsurance, and Transportation Services to a plan-approved health-related location is covered with no copay or coinsurance, while Transportation Services to any other health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the CDPHP Focus (PPO) plan. Emergency Services have a $90 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Services have a copay depending on the service, including $90 for Worldwide Emergency Coverage, $55 for Worldwide Urgent Coverage, and $255 for Worldwide Emergency Transportation.
Primary Care See details
Primary Care benefits include coverage for 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-$40 copay, Mental Health Specialty Services with a $40 copay, Physical Therapy and Speech-Language Pathology Services with a $40 copay, Additional Telehealth Benefits with a $0-$40 copay, and Opioid Treatment Program Services with no copay. Podiatry Services are not covered.
Preventive Services See details
The CDPHP Focus (PPO) plan covers preventive services, including annual physical exams, additional preventive services, health education, kidney disease education services, and other preventive services. Weight management programs have a maximum benefit coverage amount of $100 per year. Some services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, and home-based palliative care.
Hearing Services See details
Hearing Services include Hearing Exams and Prescription Hearing Aids. Hearing Exams have a $45 copay, and Routine Hearing Exams are limited to 1 visit every year with a copay between $0 and $45; Fitting/Evaluation for Hearing Aids has no copay. Prescription Hearing Aids (all types) have a copay between $599 and $899 for 2 visits every year, but Prescription Hearing Aids for the Inner Ear, Outer Ear, and Over the Ear are not covered. OTC Hearing Aids are not covered.
Vision Services See details
The CDPHP Focus (PPO) plan covers vision services, including eye exams with a $40 copay, and routine eye exams with a $20 copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered, with a combined maximum benefit of $175 per year for eyewear, but upgrades are not covered.
Dental Services See details
The CDPHP Focus (PPO) plan covers dental services with a $40 copay for Medicare dental services. Other dental services 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. Orthodontic services have a maximum plan benefit of $1,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20% and a copay of $35.
Dialysis Services See details
Dialysis Services are covered under the CDPHP Focus (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have a $10 copay and between 0% and 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a copay for diagnostic procedures/tests ranging from $0 to $40 and a $0 copay for lab services. Diagnostic Radiological Services have a copay of at least $135, while Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a copay of $35.
Home Health Services See details
Home Health Services are covered by the CDPHP Focus (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the CDPHP Focus (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CDPHP Focus (PPO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $145 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Under the CDPHP Focus (PPO) plan, acupuncture is covered with 50% coinsurance. Over-the-counter (OTC) items are covered with a maximum benefit of $50 every three months, and the plan offers nicotine replacement therapy as an OTC benefit. The meal benefit is covered for chronic illnesses or medical conditions that require the enrollee to remain at home for a period of time. Other services like Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing, and others are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved