CDPHP Flex (PPO)
H5042 - 012 - 0
(4.5 / 5)
CDPHP Flex (PPO) is a Medicare Advantage (Part C) Plan by CDPHP Medicare Advantage.
This page features plan details for 2024 CDPHP Flex (PPO) H5042 – 012 – 0 available in Greater Capital Region of New York State.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
CDPHP Flex (PPO) is offered in the following locations.
Plan Overview
CDPHP Flex (PPO) offers the following coverage and cost-sharing.
| Insurer: | CDPHP Medicare Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $9,550 In and Out-of-network $6,100 In-network $9,550 Out-of-network |
| Drugs Covered: | No |
Ready to sign up for CDPHP Flex (PPO) ?
Premium Breakdown
CDPHP Flex (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
CDPHP Flex (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $9,550 In and Out-of-network $6,100 In-network $9,550 Out-of-network |
| No |
| In-network | No |
| In-network | $325 copay per visit (Authorization is required.) (Referral is required.) |
| out-of-network | 30% coinsurance per visit (Authorization is required.) (Referral is required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $40 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $0-40 copay per visit (Authorization is required.) (Referral is required.) |
| out-of-network Specialist | 30% coinsurance per visit (Authorization is required.) (Referral is required.) |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-40 copay (Authorization is required.) (Referral is required.) |
| out-of-network Diagnostic tests and procedures | 30% coinsurance (Authorization is required.) (Referral is required.) |
| In-network Lab services | $0-5 copay (Authorization is required.) (Referral is required.) |
| out-of-network Lab services | 30% coinsurance (Authorization is required.) (Referral is required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $135 copay (Authorization is required.) (Referral is required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 30% coinsurance (Authorization is required.) (Referral is required.) |
| In-network Outpatient x-rays | $35 copay (Authorization is required.) (Referral is required.) |
| out-of-network Outpatient x-rays | $40 copay (Authorization is required.) (Referral is required.) |
| In-network Hearing exam | $45 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $0-45 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $0-45 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Non-routine services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Restorative services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Restorative services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Routine eye exam | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $40 copay (Authorization is not required.) (Referral is required.) |
| out-of-network Occupational therapy visit | $60 copay (Authorization is not required.) (Referral is required.) |
| In-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is not required.) (Referral is required.) |
| out-of-network Physical therapy and speech and language therapy visit | $60 copay (Authorization is not required.) (Referral is required.) |
| In-network | $255 copay (Not applicable.) (Not applicable.) |
| out-of-network | $255 copay (Not applicable.) (Not applicable.) |
| In-network | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| In-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is required.) |
| out-of-network Foot exams and treatment | $60 copay (Authorization is not required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | $35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $310 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is required.) |
| In-network Inpatient hospital – psychiatric | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is not required.) (Referral is required.) |
| out-of-network Inpatient hospital – psychiatric | 30% per stay (Authorization is not required.) (Referral is required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $60 copay (Authorization is not required.) (Referral is required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $60 copay (Authorization is not required.) (Referral is required.) |
| In-network Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient group therapy visit | $60 copay (Authorization is not required.) (Referral is required.) |
| In-network Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient individual therapy visit | $60 copay (Authorization is not required.) (Referral is required.) |
| In-network | $0 per day for days 1 through 20 $145 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is required.) |
Ready to sign up for CDPHP Flex (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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