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 (View SBC) (Formulary Pending) | |
|---|---|
| Office Visits | Under age 19: $0 copayment; Ages 19+: $15 per visit |
| Annual Adult Routine Physicals | No copayment |
| Well Child Care | No copayment |
| Specialty Office Visits | $25 per visit |
| Diagnostic/Therapeutic Services | |
| Radiology | $25/$125 (advanced) per visit [1] [2] |
| Lab Tests | $25 per visit [2] |
| Pathology | $25 per visit [2] |
| EKG/EEG | $25 per visit [2] |
| Radiation | $15 per visit |
| Chemotherapy | $15 per visit |
| Dialysis | $15 per visit |
| Women's Health Care/Reproductive Health | |
| Pap Tests | No copayment |
| Mammograms | No copayment |
| Prenatal Visits | $15 copayment for initial visit; no copayment for subsequent visits |
| Postnatal Visits | No copayment |
| Bone Density Tests | No copayment |
| Breastfeeding Services and Equipment | No copayment |
| External Mastectomy Prosthesis | 50% coinsurance |
| Family Planning Services | No copayment |
| Infertility Services | $25 per visit [3] |
| Contraceptive Drugs | No copayment [4] |
| Contraceptive Devices | No copayment [4] |
| Inpatient Hospital Surgery | No copayment |
| Physician | |
| Facility | |
| Outpatient Surgery | |
| Hospital | $100 per visit |
| Physician's Office | $15 PCP/$25 Specialist per visit |
| Outpatient Surgery Facility | $100 per visit |
| Weight Loss/Bariatric Surgery | $0 inpatient/$100 outpatient; when medically necessary |
| Emergency Department | $100 per visit (waived if admitted within 24 hours) |
| Urgent Care Facility | $25 per visit |
| Ambulance | $50 per trip |
| Telehealth | Virtual Care PCP/Specialist: $15/$25 per visit |
| Virtual Portal | Doctor On Demand®: No copayment; Behavioral Health: $15 per visit |
| Outpatient Mental Health | |
| Individual | $15 per visit, unlimited |
| Group | $15 per visit, unlimited |
| Inpatient Mental Health | No copayment, unlimited |
| Outpatient Drug/Alcohol Rehab | $15 per visit, unlimited |
| Inpatient Drug/Alcohol Rehab | No copayment, unlimited |
| Durable Medical Equipment | 50% coinsurance |
| Prosthetics | 50% coinsurance |
| Orthotics | 50% coinsurance [5] |
| Rehabilitative Care, Physical, Speech and Occupational Therapy | |
| Inpatient | No copayment, 60 days max |
| Outpatient Physical or Occupational Therapy | $25 per visit, 30 visits max per calendar year |
| Outpatient Speech Therapy | $25 per visit, 20 visits max per calendar year |
| Diabetic Supplies | |
| Retail | $15 per item, 30-day supply |
| Mail Order | $30 per item, 90-day supply |
| Insulin and Oral Agents | |
| Retail | $0/$15 per item, 30-day supply [6] |
| Mail Order | $30 per item, 90-day supply |
| Diabetic Shoes | $15 per pair, one pair per year when medically necessary |
| Hospice | No copayment, 210 days max |
| Skilled Nursing Facility | No copayment, 45 days max |
| Prescription Drugs | |
| Retail | $5 Tier 1 ($0 Tier 1 for under age 19), $30 Tier 2, $50 Tier 3 at preferred pharmacies, 30-day supply [7] |
| Mail Order | $10 Tier 1, $60 Tier 2, $100 Tier 3, 90-day supply |
| Additional Prescription Drug Related Information | Over-the-counter formulary drugs are subject to Tier 1 copayment. By law, generics match brand-name strength, purity and stability. Ask your doctor about generic alternatives, or download our pharmacy app, Connect Rx On the Go. |
| Specialty Drugs | Certain specialty drugs 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) | $6,350 Individual; $12,700 Family per year |
| Dental | Not covered |
| Vision | Not covered |
| Hearing Aids | $599/$899 copayment per hearing aid. [8] |
| Out of Area | Coverage for emergency care as well as preapproved follow-up care for college students. |
| Additional Benefits HMOs (as applicable) | |
| Allergy Injections | No copayment |
| Acupuncture | $25 per visit, 10 visits max |
| Diabetic Prevention Program | No copayment |
| Laser Vision Correction | $750 reimbursement, once per lifetime benefit |
| Plan Highlights for 2025 | $0 PCP visits and Tier 1 Rx for members under age 19. Up to $2,640 in wellness benefits, including $600 fitness reimbursement (youth sports, gyms, fitness classes, activity trackers), $365 in CDPHP Life Points Rewards redeemable for gift cards, $100 for weight loss programs, up to $1,500 per pregnancy for doula services, and $75 maternal health education. College students/travelers can access video doctor visits, such as Doctor On Demand®, with no copay and 1,100+ CVS MinuteClinic locations. |
| Participating Physicians | CDPHP has nearly 24,000 participating practitioners and providers. Urgent and emergent care covered worldwide. |
| 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 | Visit www.cdphp.com/stateemployees for information about our preferred pharmacy network and discount medication program and to download our pharmacy app, CDPHP ConnectRx On the Go. |
| Medicare Coverage | Medicare-primary NYSHIP retirees and dependents must enroll in CDPHP Group Medicare Rx (HMO), our Medicare Advantage Plan. To qualify, you must have Medicare Parts A and B and live in the service area. |