High-quality health insurance for $0 per month
Find out if you qualify for an Essential Plan
CDPHP® ESSENTIAL PLAN BENEFIT OVERVIEW
View CDPHP® Essential Plan Benefit Overview Summary (PDF).
| ESSENTIAL PLAN 200-250 |
|
Single person with annual income
between $30,121-$37,650
|
|
Monthly Premium
$0
|
|
Max. Out of Pocket per Individual
$2,000
|
|
SERVICES COPAY OR COINSURANCE PER VISIT
|
|
Preventive Care*, Annual Physical Exam
$0
|
|
Primary Care Doctor Visit
$15
|
|
Specialist Doctor Visit
$25
|
|
Clinical/Diagnostic Lab/X-ray/MRI/CT Scan/PET Scan
$25
|
|
Live Video Doctor Visits
$15
|
|
Outpatient Facility, Surgeon
$50
|
|
Inpatient Hospital, Nursing Facility
$150 per admission
|
|
Outpatient Mental Health and Substance Use Services
$15
|
|
Emergency Room, Ambulance
$75
|
|
Urgent Care
$25
|
|
PT/OT/ST
$15
|
|
Chiropractic Services
$25
|
|
Eye Exams
$0
|
|
Dental
$0
|
|
SUPPLIES AND PRESCRIPTIONS
COPAY OR COINSURANCE PER ITEM
|
|
Durable Medical Equipment (DME)
5%
|
|
Diabetic Supplies
$15, 30 Day Supply
|
|
Hearing Aids (External)
5%
|
|
Eyewear
0%
|
|
Prescription Drugs:
Tier 1 Generic: $6
Tier 2 Preferred Brand: $15
Tier 3 Non Preferred Brand: $30
Mail Order 90 Day Supply: 2.5x Copay
|
| ESSENTIAL PLAN 1 |
|
Single person with annual income
between $22,591-$30,120
|
|
Monthly Premium
$0
|
|
Max. Out of Pocket per Individual
$360
|
|
SERVICES COPAY OR COINSURANCE PER VISIT
|
|
Preventive Care*, Annual Physical Exam
$0
|
|
Primary Care Doctor Visit
$15
|
|
Specialist Doctor Visit
$25
|
|
Clinical/Diagnostic Lab/X-ray/MRI/CT Scan/PET Scan
$25
|
|
Live Video Doctor Visits
$15
|
|
Outpatient Facility, Surgeon
$50
|
|
Inpatient Hospital, Nursing Facility
$150 per admission
|
|
Outpatient Mental Health and Substance Use Services
$15
|
|
Emergency Room, Ambulance
$75
|
|
Urgent Care
$25
|
|
PT/OT/ST
$15
|
|
Chiropractic Services
$25
|
|
Eye Exams
$0
|
|
Dental
$0
|
|
SUPPLIES AND PRESCRIPTIONS
COPAY OR COINSURANCE PER ITEM
|
|
Durable Medical Equipment (DME)
5%
|
|
Diabetic Supplies
$15, 30 Day Supply
|
|
Hearing Aids (External)
5%
|
|
Eyewear
0%
|
|
Prescription Drugs:
Tier 1 Generic: $6
Tier 2 Preferred Brand: $15
Tier 3 Non Preferred Brand: $30
Mail Order 90 Day Supply: 2.5x Copay
|
| ESSENTIAL PLAN 2 |
|
Single person with annual income
between $20,783-$22,590
|
|
Monthly Premium
$0
|
|
Max. Out of Pocket per Individual
$200
|
|
SERVICES COPAY OR COINSURANCE PER VISIT
|
|
Preventive Care*, Annual Physical Exam
$0
|
|
Primary Care Doctor Visit
$0
|
|
Specialist Doctor Visit
$0
|
|
Clinical/Diagnostic Lab/X-ray/MRI/CT Scan/PET Scan
$0
|
|
Live Video Doctor Visits
$0
|
|
Outpatient Facility, Surgeon
$0
|
|
Inpatient Hospital, Nursing Facility
$0 per admission
|
|
Outpatient Mental Health and Substance Use Services
$0
|
|
Emergency Room, Ambulance
$0
|
|
Urgent Care
$0
|
|
PT/OT/ST
$0
|
|
Chiropractic Services
$0
|
|
Eye Exams
$0
|
|
Dental
$0
|
|
SUPPLIES AND PRESCRIPTIONS
COPAY OR COINSURANCE PER ITEM
|
|
Durable Medical Equipment (DME)
0%
|
|
Diabetic Supplies
0%
|
|
Hearing Aids (External)
0%
|
|
Eyewear
0%
|
|
Prescription Drugs:
Tier 1 Generic: $1
Tier 2 Preferred Brand: $3
Tier 3 Non Preferred Brand: $3
Mail Order 90 Day Supply: 2.5x Copay
|
| ESSENTIAL PLAN 3** |
|
Single person with annual income
between $15,060-$20,783
|
|
Monthly Premium
$0
|
|
Max. Out of Pocket per Individual
$200
|
|
SERVICES COPAY OR COINSURANCE PER VISIT
|
|
Preventive Care*, Annual Physical Exam
$0
|
|
Primary Care Doctor Visit
$0
|
|
Specialist Doctor Visit
$0
|
|
Clinical/Diagnostic Lab/X-ray/MRI/CT Scan/PET Scan
$0
|
|
Live Video Doctor Visits
$0
|
|
Outpatient Facility, Surgeon
$0
|
|
Inpatient Hospital, Nursing Facility
$0 per admission
|
|
Outpatient Mental Health and Substance Use Services
$0
|
|
Emergency Room, Ambulance
$0
|
|
Urgent Care
$0
|
|
PT/OT/ST
$0
|
|
Chiropractic Services
$0
|
|
Eye Exams
$0
|
|
Dental
$0
|
|
SUPPLIES AND PRESCRIPTIONS
COPAY OR COINSURANCE PER ITEM
|
|
Durable Medical Equipment (DME)
0%
|
|
Diabetic Supplies
0%
|
|
Hearing Aids (External)
0%
|
|
Eyewear
0%
|
|
Prescription Drugs:
Tier 1 Generic: $1
Tier 2 Preferred Brand: $3
Tier 3 Non Preferred Brand: $3
Mail Order 90 Day Supply: 2.5x Copay
|
| ESSENTIAL PLAN 4** |
|
Single person with annual income
below $15,060
|
|
Monthly Premium
$0
|
|
Max. Out of Pocket per Individual
$0
|
|
SERVICES COPAY OR COINSURANCE PER VISIT
|
|
Preventive Care*, Annual Physical Exam
$0
|
|
Primary Care Doctor Visit
$0
|
|
Specialist Doctor Visit
$0
|
|
Clinical/Diagnostic Lab/X-ray/MRI/CT Scan/PET Scan
$0
|
|
Live Video Doctor Visits
$0
|
|
Outpatient Facility, Surgeon
$0
|
|
Inpatient Hospital, Nursing Facility
$0 per admission
|
|
Outpatient Mental Health and Substance Use Services
$0
|
|
Emergency Room, Ambulance
$0
|
|
Urgent Care
$0
|
|
PT/OT/ST
$0
|
|
Chiropractic Services
$0
|
|
Eye Exams
$0
|
|
Dental
$0
|
|
SUPPLIES AND PRESCRIPTIONS
COPAY OR COINSURANCE PER ITEM
|
|
Durable Medical Equipment (DME)
0%
|
|
Diabetic Supplies
0%
|
|
Hearing Aids (External)
0%
|
|
Eyewear
0%
|
|
Prescription Drugs:
Tier 1 Generic: $0
Tier 2 Preferred Brand: $0
Tier 3 Non Preferred Brand: $0
Mail Order 90 Day Supply: $0
|
* For certain preventive care visits and services, as defined under section 2713 of the Affordable Care Act, there is 100% coverage with no cost sharing
** Available to those not eligible for Medicaid due to immigration status; dental services provided by Delta Dental