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Complete Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Complete Rx (PPO) in 2025, please refer to our full plan details page.
Complete 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 Complete 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 Complete 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 Complete Rx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $70.00. 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 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 Complete Rx (PPO) plan has an "Enhanced Alternative" drug benefit. The plan has no deductible. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, Preferred Generic drugs have no copay at preferred pharmacies and preferred mail order, but a $19 copay at standard pharmacies and standard mail order. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Complete Rx (PPO) plan offers a variety of benefits with varying costs. The plan includes inpatient hospital stays with a copay, and outpatient services like doctor visits and outpatient substance abuse services, with copays ranging from $0 to $325. Emergency, primary care, and preventive services are also covered, often with no copay, alongside hearing, vision, and dental services with copays and annual maximums. Additional benefits include home health services with no copay, skilled nursing facility care with a copay after the first 20 days, and coverage for medical equipment and various diagnostic services with coinsurance. The plan also provides coverage for acupuncture, over-the-counter items, and a meal benefit, while some services like cardiac rehabilitation are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a $310 copay for days 1-6 and no copay for days 7-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are covered. 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 are covered by the Complete Rx (PPO) plan, including outpatient hospital services with a $325 copay, observation services with a $310 copay, and ambulatory surgical center services with a $275 copay. Outpatient substance abuse services have a $40 copay for both individual and group sessions, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Complete Rx (PPO) covers partial hospitalization with a doctor's referral, with a copay of $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Complete Rx (PPO) plan, with prior authorization required. Ground and air ambulance services have a copay of $255, and transportation services to a plan-approved health-related location are covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services and Worldwide Emergency Coverage have a $120 copay, Urgently Needed Services and Worldwide Urgent Coverage have a $55 copay, and Worldwide Emergency Transportation has a $255 copay; all services have no coinsurance.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $15 copay (referral required), Occupational Therapy Services with a $40 copay, Physician Specialist Services with a copay between $0 and $40 (prior authorization and referral required), Mental Health Specialty Services with a $40 copay for individual and group sessions (referral required), Physical Therapy and Speech-Language Pathology Services with a $40 copay (referral required), and Additional Telehealth Benefits with a copay between $0 and $40. Opioid Treatment Program Services are covered with no copay. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, and additional preventive services; however, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. The plan also covers Health Education, Weight Management Programs, Nutritional/Dietary Benefit, In-Home Support Services, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Kidney Disease Education Services, and Other Preventive Services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Weight Management Programs have a maximum plan benefit coverage amount of $100 every year, while Glaucoma Screening, Diabetes Self-Management Training, and EKG following Welcome Visit have a $0 maximum out-of-pocket amount. Kidney Disease Education Services require a doctor referral and have no copay.
Hearing Services See details
The Complete Rx (PPO) plan covers hearing exams with a $40 copay, and routine hearing exams with a copay between $0 and $45. Fitting/evaluation for hearing aids have no copay, while prescription hearing aids have 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 coverage for eye exams with a $40 copay, and routine eye exams with a $20 copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are covered, with a combined maximum benefit of $225 per year for eyewear. Upgrades are not covered.
Dental Services See details
The Complete Rx (PPO) plan covers Medicare Dental Services with a $40 copay, and covers other dental services with a maximum plan benefit of $1400 per year. 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), maxillofacial prosthetics, implant services, prosthodontics (fixed), oral and maxillofacial surgery, and orthodontics are all covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Other Medicare Part B Drugs have a copay of $35, and a coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Complete Rx (PPO) plan. The coinsurance for Dialysis Services is between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 25% coinsurance up to a $300 maximum, and Prosthetics/Medical Supplies with 25% coinsurance. Diabetic Equipment is covered with 25% coinsurance and a $10 copay, while Diabetic Supplies have a $10 copay and 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have 25% 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 coinsurance of at most 20%, Lab Services with no copay, Diagnostic Radiological Services with a copay of at most $135, and Therapeutic Radiological Services with a coinsurance of at most 20%. Outpatient X-Ray Services have a $5 copay.
Home Health Services See details
Home Health Services are covered by the Complete Rx (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 Complete Rx (PPO) plan. Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Complete Rx (PPO) plan, with a doctor referral and prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $145.
Other Services See details
Other Services include acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture has a 50% coinsurance, and is limited to 10 treatments per year. OTC items are covered as a supplemental benefit under Part C, with a maximum benefit coverage amount of $50 every three months, and the plan offers Nicotine Replacement Therapy (NRT). The meal benefit is provided for a chronic illness or a medical condition that requires the enrollee to remain at home for a period of time. 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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