2017 BENEFIT SUMMARY COMPARISON
CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (HMO)
Your Annual Cost to Enroll
Albany Central NY
Individual: $1,547.40 $1,707.29
2 Person: $3,868.50 $4,268.25
Family: $5,029.05 $5,548.71
2017 HMO $25
In Network
Annual Deductible None
Coinsurance None
Annual Out of Pocket Maximum $7,150 Individual/$14,300 Family
Annual Maximum Benefit Unlimited
Lifetime Maximum Benefit Unlimited
Dependent Coverage to Age 26
Inpatient Hospitalization $500 co-pay
Outpatient Hospital Surgery $75 co-pay
Well Child Care Covered In Full
Annual Gynecological Visit Covered In Full
Routine Mammograms Covered In Full
Maternity $500 In-Patient co-pay imposed
Immunizations Covered In Full
Annual Physical Exam Covered In Full
Physician Office Visit $25 co-pay
Specialist Office Visit $40 co-pay
Diagnostic Radiology $40 co-pay, waived at preferred facilities
Diagnostic Laboratory Tests $40 co-pay,waived at preferred facilities
Dental Not covered
Routine Vision Exam w/discount for hardware One every 2 years, $40 co-pay; $75 allow for lenses, frames or contacts
Physical & Occupational Therapy $40 co-pay, 30 visits
Speech Therapy $40 co-pay, 20 visits
Chiropractic $40 co-pay
Mental Health Inpatient $500 co-pay
Mental Health Outpatient $25 co-pay
Alcohol/Substance Abuse Inpatient - Detox/Rehab $500 co-pay
Alcohol/Substance Abuse Outpatient $25 co-pay
Durable Medical Equipment 50% co-insurance
Ambulance $100 co-pay
Emergency Room Care $100 co-pay
Urgent Care $35.00
Prescription Drugs (Retail) 30 day supply $10 Generic/$40 Brand/$70 NF
Prescription Drugs (Mail Order) 90 day supply $25 Generic/$100 Brand/$175 NF
Inpatient Hospitalization Precertification Yes
Infertility Treatment Covered-refer to contract details
Primary Care Physician Required Yes
Specialty Referral Required Yes

1. The above comparison is a summary only designed as a quick reference to help you select a plan. More detailed information is in the material distributed by the HMO.

2. Abortions are excluded from coverage.

3. The CDPHP HMO PLAN offers in-network HMO coverage only.

4. Core benefit changes for 2017 are highlighted.

5. See other benefit summaries for comparisons of other plans being offered.

6. Visit their website at www.cdphp.com