2022 CDPHP Vital Rx (PPO)

CDPHP Vital Rx (PPO) H5042-009 is a 2022 Medicare Advantage Plan or Part-C by CDPHP Medicare Advantage available to residents in New York. This plan includes additional prescription drug (Part-D) coverage. The CDPHP Vital Rx (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,500 out-of-pocket. This can be a extremely nice safety net.

CDPHP Vital Rx (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

CDPHP Medicare Advantage works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for CDPHP Vital Rx (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from CDPHP Medicare Advantage and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from CDPHP Medicare Advantage except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 CDPHP Medicare Advantage Medicare Advantage Plan Costs

CDPHP Vital Rx (PPO) Part-C Premium

CDPHP Medicare Advantage charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H5042-009 Part-D Deductible and Premium

CDPHP Vital Rx (PPO) has a monthly drug premium of $0.00 and a $350.00 drug deductible. This CDPHP Medicare Advantage plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by CDPHP Medicare Advantage above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

CDPHP Medicare Advantage Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This CDPHP Medicare Advantage plan does not offer additional coverage through the gap.

H5042-009 Formulary or Drug Coverage

CDPHP Vital Rx (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 CDPHP Vital Rx (PPO) H5042-009 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$3
Tier 2	NA	$17
Tier 3	NA	$47
Tier 4	NA	$100
Tier 5	NA	26%

*Initial Coverage Phase and 30 day supply

2021 CDPHP Vital Rx (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$220 copay
Diagnostic tests and procedures	0-20% coinsurance
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Lab services	40% coinsurance (Out-of-Network)
Lab services	0-20% coinsurance
Outpatient x-rays	$50 copay
Outpatient x-rays	$50 copay (Out-of-Network)

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Doctor Visits

Primary	$50 copay per visit (Out-of-Network)
Primary	$0 copay
Specialist	$50 copay per visit
Specialist	$60 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$65 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$50 copay
Foot exams and treatment	$60 copay (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$265 copay
$265 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$0-45 copay (Out-of-Network)
Hearing aids	$599-899 copay
Hearing aids	$599-899 copay (Out-of-Network)
Hearing exam	$45 copay
Hearing exam	$0-45 copay (Out-of-Network)

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Inpatient Hospital Coverage

40% per stay (Out-of-Network)
$460 per day for days 1 through 4 $0 per day for days 5 through 90

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Medical Equipment/Supplies

Diabetes supplies	40% coinsurance per item (Out-of-Network)
Diabetes supplies	0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	40% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	40% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$330 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	$60 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$60 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$60 copay (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	$60 copay (Out-of-Network)

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MOOP

$11,300 In and Out-of-network $7,500 In-network $11,300 Out-of-network

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Option

Yes, contact plan for further details

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

40% coinsurance per visit (Out-of-Network)
$395 copay per visit

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Preventive Care

40% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	Covered under office visit
Dental x-ray(s)	$20-30 copay (Out-of-Network)
Dental x-ray(s)	$20-30 copay
Fluoride treatment	Not covered
Office visit	$20-30 copay (Out-of-Network)
Office visit	$20.00
Oral exam	Covered under office visit

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Rehabilitation Services

Occupational therapy visit	$60 copay (Out-of-Network)
Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay
Physical therapy and speech and language therapy visit	40% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100
40% per stay (Out-of-Network)

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Transportation

$0 copay
$0 copay (Out-of-Network)

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	40% coinsurance (Out-of-Network)
Routine eye exam	$20 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for CDPHP Vital Rx (PPO) H5042

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in CDPHP Vital Rx (PPO) Plans Performance

Health Plan Customer Service Rating for CDPHP Vital Rx (PPO)

CDPHP Vital Rx (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for CDPHP Vital Rx (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.