2025 NYSHIP Plan Comparison
Disclaimer: Please visit your HMO's website for the most up-to-date benefit information and any mid-year prescription drug formulary changes.
| CDPHP HMO - Medicare Advantage Plan (View Drug Formulary) | |
|---|---|
| Office Visits | $15 per visit |
| Annual Adult Routine Physicals | No copayment |
| Well Child Care | |
| Specialty Office Visits | $20 per visit |
| Diagnostic/Therapeutic Services | |
| Radiology | $20/$40 per visit [1] [2] |
| Lab Tests | $0/$20 per visit [3] |
| Pathology | $20 per visit |
| EKG/EEG | $20 per visit |
| Radiation | $20 per visit |
| Chemotherapy | $20 per visit |
| Dialysis | $20 per visit |
| Women's Health Care/Reproductive Health | |
| Pap Tests | No copayment |
| Mammograms | No copayment |
| Prenatal Visits | $20 per visit |
| Postnatal Visits | $20 per visit |
| Bone Density Tests | No copayment |
| Breastfeeding Services and Equipment | Not covered |
| External Mastectomy Prosthesis | 20% coinsurance |
| Family Planning Services | $20 per visit |
| Infertility Services | $20 per visit |
| Contraceptive Drugs | Applicable Rx copayment |
| Contraceptive Devices | Applicable Rx copayment |
| Inpatient Hospital Surgery | No copayment |
| Physician | |
| Facility | |
| Outpatient Surgery | |
| Hospital | $75 per visit |
| Physician's Office | $75 per visit |
| Outpatient Surgery Facility | $75 per visit |
| Weight Loss/Bariatric Surgery | $0 inpatient/$75 outpatient; when medically necessary |
| Emergency Department | $75 per visit (waived if admitted within 24 hours) |
| Urgent Care Facility | $30 per visit |
| Ambulance | $75 per trip |
| Telehealth | Virtual care PCP/Specialist: $15/$20 per visit |
| Virtual Portal | Doctor On Demand®: No copayment; Behavioral Health: $15 per visit |
| Outpatient Mental Health | |
| Individual | $20 per visit, unlimited |
| Group | $20 per visit, unlimited |
| Inpatient Mental Health | No copayment, 190 days max per lifetime [4] |
| Outpatient Drug/Alcohol Rehab | $20 per visit, unlimited |
| Inpatient Drug/Alcohol Rehab | No copayment, unlimited |
| Durable Medical Equipment | 20% coinsurance |
| Prosthetics | 20% coinsurance |
| Orthotics | 20% coinsurance |
| Rehabilitative Care, Physical, Speech and Occupational Therapy | |
| Inpatient | No copayment, unlimited |
| Outpatient Physical or Occupational Therapy | $20 per visit, unlimited |
| Outpatient Speech Therapy | $20 per visit, unlimited |
| Diabetic Supplies | 20% coinsurance or $10 copayment, whichever is less, up to a 30-day supply [5] |
| Retail | |
| Mail Order | |
| Insulin and Oral Agents | Applicable Rx copayment |
| Retail | |
| Mail Order | |
| Diabetic Shoes | 20% coinsurance, one pair per year when medically necessary |
| Hospice | Covered by Medicare |
| Skilled Nursing Facility | No copayment, 100 days max |
| Prescription Drugs | |
| Retail | $0 Tier 1, $10 Tier 2, $30 Tier 3, $50 Tier 4, $55 Tier 5 at preferred pharmacies, 30-day supply [6] [7] |
| Mail Order | $0 Tier 1, $20 Tier 2, $60 Tier 3, $100 Tier 4, N/A Tier 5, 90-day supply |
| Additional Prescription Drug Related Information | |
| Specialty Drugs | Some specialty drugs for serious conditions require prior approval, are subject to clinical management programs and must be filled by a network specialty pharmacy. |
| Additional Benefits | |
| Annual Out-of-Pocket Maximum (In-Network Benefits) | $2,500 per year [8] |
| Dental | $150 reimbursement for office visits; up to two cleanings annually. |
| Vision | $20 per visit [9] |
| Hearing Aids | $199/$499 copayment per hearing aid. [10] |
| Out of Area | Get urgently-needed care from any provider when outside the service area and emergency care worldwide. All other care requires prior authorization. |
| Additional Benefits HMOs (as applicable) | |
| SeniorFit | No-cost gym membership at CDPHP Fitness Connect at the Ciccotti Center and SilverSneakers locations. |
| Weight Loss Reimbursement | Once-per-benefit-period reimbursement of up to $100 for completing a weight loss program with a preferred vendor. |
| Acupuncture | 50% coinsurance, 10 visits max |
| Plan Highlights for 2025 | $0 Doctor On Demand® visits. $0 Tier 1 prescriptions. Earn up to $125 in gift cards for completing healthy activities and get $100 for completing a weight loss program. Get 30 hours of companionship and help with everyday tasks at home. Hearing aids $199/$499. Fourteen free meals delivered to your home at no cost after an inpatient stay. No-cost SilverSneakers fitness membership. |
| Participating Physicians | CDPHP has nearly 24,000 participating practitioners and providers. |
| Affiliated Hospitals | CDPHP is affiliated with most major hospitals in our service area. An out-of-network facility or Center of Excellence can be approved for special care needs. |
| Pharmacies and Prescriptions | CDPHP offers a Part D formulary and network pharmacies nationwide. Log in to Rx Corner at www.cdphp.com/statemedicareretirees to view claims. Mail order saves money; find forms online or call 518-641-3950 or 1-888-248-6522. |
| Medicare Coverage | Medicare-primary NYSHIP retirees and dependents must enroll in CDPHP Group Medicare Rx (HMO). To qualify, you must have Medicare Parts A and B and live in the service area. |