CDPHP Flex Rx (PPO) H5042-011-0 Plan Details
CDPHP Flex Rx (PPO) H5042-011-0 Plan Details
Navigating your Medicare Advantage options for 2025 can be overwhelming, but we're here to help. With CDPHP Flex Rx (PPO) included in your plan options, you can evaluate it alongside other plans to make an informed decision. Enroll online quickly, or consult with a licensed agent if you need assistance.
CDPHP Flex Rx Overview
Plan ID H5042-011-0 Overview | |
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Health Plan ID: | H5042-011-0 |
Medicare Advantage Plan Type: | Local PPO |
Plan Year: | 2024 |
Monthly Premium: | $34.80 Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Annual Out-of-Pocket Maximum: | $6,100 |
Part B Give Back: | $0.00/mo |
Part D Drug Plan Benefit: | Enhanced, $0.00 deductible |
Part D Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | See List |
Insured By: | CDPHP Medicare Advantage |
Why Consider CDPHP Flex Rx?
CDPHP Flex Rx is a Medicare Advantage Prescription Drug (MAPD) Preferred Provider Organization (PPO) plan that combines flexibility with extensive healthcare coverage. With a monthly premium of $34.80, this plan covers the core services of Medicare Part A and Part B, along with additional benefits like prescription drug coverage. There is no annual deductible. Cost sharing begins with your first prescription. As a PPO plan, you have the freedom to see any provider, but in-network services will generally cost less.
A key advantage of CDPHP Flex Rx is its financial protection, with an annual maximum out-of-pocket (MOOP) limit of $6,100. Once you hit this limit, the plan covers 100% of your in-network healthcare costs for the rest of the year. This makes CDPHP Flex Rx a dependable option for those who seek a balance between comprehensive coverage and provider flexibility.
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Cost-Sharing Overview
With CDPHP Flex Rx, you'll have cost-sharing expenses, which are the out-of-pocket costs for approved healthcare services. The table below provides a summary of the typical in-network out-of-pocket costs associated with plan H5042-011-0.
Service | Enrollee Cost |
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Doctor's Office Visit (In-Network) | |
Primary: | $0 Copay |
Specialist: | $40 Copay Prior Authorization Required, Referral Required |
Wellness & Preventive Programs: | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot Exams and Treatments (Medicare-covered): | $40 Copay Referral Required |
Routine Foot Care: | Not Covered |
Chiropractic Treatment (In-Network) | |
Medicare-covered chiropractic: | $15 Copay Referral Required |
Routine chiropractic: | Not Covered |
Emergency and Urgent Care | |
Emergency room care: | $90 Copay |
Urgent care: | $55 Copay |
Ground ambulance: | $255 Copay |
Inpatient hospital care: | $310.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Outpatient hospital care: | $250 Copay Prior Authorization Required, Referral Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $145.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy: | $40 Copay |
Outpatient group therapy: | $40 Copay |
Inpatient psychiatric hospital care: | $300.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy: | $40 Copay |
Outpatient individual therapy: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy: | $40 Copay Referral Required |
Occupational therapy: | $40 Copay Referral Required |
Medical Equipment and Supplies (In-Network) | |
Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging (In-Network) | |
Diagnostic radiology services: | $135 Copay Prior Authorization Required, Referral Required |
Lab services: | $5 Copay Prior Authorization Required, Referral Required |
Outpatient x-rays: | $35 Copay Prior Authorization Required, Referral Required |
Diagnostic tests and procedures: | $40 Copay Prior Authorization Required, Referral Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Most preventive services are covered 100% by CDPHP Flex Rx as a Part B benefit.
Supplemental Benefits
Here’s an overview of the additional benefits that CDPHP Medicare Advantage offers with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $0 Copay Limitations Apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $45 Copay |
Vision | Maximum vision benefit: | $175.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | $20 Copay |
Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Part D Prescription Drug Costs & Benefits
CDPHP Flex Rx includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
While the prescription drug plan (Part D) premium is included in the overall plan cost, some plans may have additional costs or provide assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security program that assists individuals with limited income and resources in reducing or eliminating Part D expenses.
The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $34.80 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $34.80 |
Part D Premium with Full LIS Assistance: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. You must pay this amount at the pharmacy before CDPHP Medicare Advantage begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, CDPHP Flex Rx has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | $0.00 copay | $5.00 copay |
2 (Generic) | $0.00 copay | $19.00 copay |
3 (Preferred Brand) | $44.00 copay | $47.00 copay |
4 (Non-Preferred Drug) | $95.00 copay | $95.00 copay |
5 (Specialty Tier) | 33% | 33% |
Understanding CMS Star Ratings
The Centers for Medicare & Medicaid Services (CMS) reviews and rates Medicare Advantage (Part C) and drug plans (Part D) annually, using a 5-star system to measure aspects such as member satisfaction, preventive services, and management of chronic conditions.
Higher star ratings generally indicate better plan performance, which can be a useful factor to consider when deciding on a plan that aligns with your healthcare goals and preferences.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Plan Availability
CDPHP Flex Rx (H5042-011-0) is available in the following locations (click to open):
Am I Eligible for CDPHP Flex Rx?
To enroll in CDPHP Flex Rx, you must meet the following criteria:
- Be eligible for Medicare Part A and Part B.
- Reside in the plan’s service area.
- Not have End-Stage Renal Disease (ESRD), with some exceptions.
If you meet these requirements, you are eligible to enroll in CDPHP Flex Rx and benefit from its comprehensive coverage options.
When Should You Enroll in CDPHP Flex Rx?
To ensure you don’t miss your chance to enroll in CDPHP Flex Rx, be aware of these important enrollment periods:
- Initial Enrollment Period (IEP): Your IEP offers a seven-month window around your 65th birthday to sign up for Medicare.
- Annual Enrollment Period (AEP): The AEP, occurring from October 15 to December 7 each year, allows you to enroll in or make changes to your Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31, the MA OEP provides an opportunity to switch Medicare Advantage plans or return to Original Medicare.
- Special Enrollment Periods (SEPs): Certain life changes, like moving or losing insurance coverage, may qualify you for a SEP, giving you a chance to make adjustments outside the standard periods.
Need help figuring out the right time to enroll? Call HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711) to get assistance from a licensed insurance agent.
Steps to Enroll in CDPHP Flex Rx
Joining CDPHP Flex Rx is straightforward. Here are the steps you can take:
- Online: Use our online enrollment partner's Secure Online Enrollment Form to sign up.
- By Phone: Reach out to HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711). A licensed insurance agent will help you with the enrollment process and answer any questions you might have.
- Through Medicare.gov: Enroll directly through the official Medicare website. Visit Medicare.gov, log in or create an account, and follow the steps to join CDPHP Flex Rx.
- Direct Enrollment: You can also choose to enroll directly with CDPHP Flex Rx. The contact information can be found below in the "Contact" section.
Make sure you enroll during the appropriate period to activate your coverage as soon as possible.
Contact CDPHP Medicare Advantage
Website: | https://www.cdphp.com/medicare |
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Formulary: | https://findadoc.cdphp.com/ |
Pharmacy: | CDPHP Medicare Advantage Pharmacy Page |
New Members: | (888)519-4455 |
TTY Users: | 711 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, you can do so on the Social Security Administration website. For more information about the Medicare Part C program, visit the official Medicare website or call 1-800-MEDICARE.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
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