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DEVOTED CHOICE 003 KY (PPO) - H5718-003-000
$0.00
Monthly Premium
DEVOTED CHOICE 003 KY (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H5718-003-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Kentucky Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.
Learn more about Kentucky Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $650.00 |
| Out-of-pocket maximum | $6,050.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $5 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $25 to $40 Prior Authorization Required for Doctor Specialty Visit The min cost share applies to balance exams. The max cost share applies to wound care services and specialist services. |
| Inpatient hospital care | In-Network: Acute Hospital Services: $375 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 to $45 The min cost share applies to urgently needed services received by a PCP. The max cost share applies to urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $130 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $130 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation $375 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Ambulance transportation | Ground Ambulance: Copayment for Ground Ambulance Services $0 to $375 Cost share applies per trip. Min cost share for facility to facility transfers. Max cost share for all other ambulance services. Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED CHOICE 003 KY (PPO) covers a range of additional benefits. Learn more about DEVOTED CHOICE 003 KY (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 50%
Dexcom Continuous Glucose Monitors (CGMs) and Supplies (Preferred): Coinsurance when obtained at a retail pharmacy 50% Coinsurance when obtained through a Durable Medical Equipment provider 50% Non-Preferred CGMs and Supplies: Coinsurance when obtained at a retail pharmacy 50%
Please see the Evidence of Coverage for full glucose monitor benefit information. |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% The max coinsurance applies to the following DME: Medicare-covered ventilator, Bone growth stimulator, Portable oxygen concentrator, Bariatric equipment, Specialty beds, Custom or specialty wheelchairs and scooters, Seat lifts, Specialty brand items, High Frequency Chest Compression Vests, Pain Infusion Pump, and Home Infusion Therapy (HIT) drugs. The min coinsurance applies to all other DME |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Diagnostic Procedures/Tests Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare-covered Lab Services $0 to $40 Coinsurance for Genetic Testing 15% Copayment for Medicare-covered Diagnostic Radiological Services $25 to $300 Coinsurance for Medicare-covered Therapeutic Radiological Services 40% Copayment for Medicare-covered Outpatient X-Ray Services $0 to $75 The min cost share applies to home sleep studies and other diagnostic tests at a PCP office or in the home. The mid cost share applies to EKGs/EEGs/ECGs at a PCP, specialist office, or freestanding facility and all other diagnostic tests at a specialist office or freestanding facility. The max cost share applies to EKGs/EEGs/ECGs and all other diagnostic tests at an outpatient hospital. |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $375 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Mental Health Services: Copayment for Medicare Covered Individual Sessions $40 Copayment for Medicare Covered Group Sessions $40 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $475 Prior Authorization Required for Outpatient Hospital Services The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $375 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $375 Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other ASC services. |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $40 Copayment for Medicare Covered Group Sessions $40 |
| Over-the-counter items | Over-the-Counter Items (OTC): $62 per quarter to use toward the purchase of eligible over-the-counter (OTC) items at participating locations. You get the most out of your OTC benefits when you shop at participating locations. If you purchase items at non-participating stores, you will be responsible for a 90% coinsurance. Please see Evidence of Coverage for full benefit details. |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $40 |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 40% |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Copayment for office visit $40 Prior Authorization may be required. Dental Allowance: You have a $3,500 yearly allowance toward Preventive Dental and Comprehensive Dental. You can see any licensed dentist in the United States. You will pay the costs yourself at first. Then, you can submit a request for reimbursement to Devoted. For all covered preventive dental services, like exams and routine cleanings, you will receive 100% reimbursement up to the yearly allowance. For all covered comprehensive dental services, you will receive 50% reimbursement up to the yearly allowance. Covered dental services are limited to specific dental codes as listed in your Evidence of Coverage, and include, but are not limited to: periodic oral exams, dental evaluations, cleanings, X-rays, fillings, deep cleanings, extractions, dentures, root canals, crowns, and bridges. Cosmetic procedures, dental implants, and/or elective procedures are not covered. See your Evidence of Coverage for a full list of covered services and coverage limitations. Non-Medicare Covered Preventive Dental: Maximum Dental Allowance of $3,500 per year. Please see Evidence of Coverage for dental code restrictions and frequency limitations. Copayment for Oral exams $0 Copayment for Dental x-rays $0 Copayment for Prophylaxis (cleanings) $0 Copayment for Fluoride treatment $0 Non-Medicare Covered Comprehensive Dental: Maximum Dental Allowance of $3,500 per year. Please see Evidence of Coverage for dental code restrictions and frequency limitations. Coinsurance for Restorative services (e.g. fillings, crowns) 50% Coinsurance for Endodontics (e.g. root canal) 50% Coinsurance for Periodontics (e.g. scaling, root planing) 50% Coinsurance for Prosthodontics, removable (e.g. dentures) 50% Coinsurance for Prosthodontics, fixed (e.g. bridges) 50% Coinsurance for Maxillofacial surgery (e.g. extractions) 50% Coinsurance for Adjunctive general services 50% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Medicare-Covered Vision Care: Copayment for Medicare-Covered Diagnostic Eye Exams $40 Copayment for Diabetic Retinopathy Exams $0 Routine Vision Care: Copayment for Routine Eye Exam $0
|
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Hearing Exams: Copayment for Medicare-covered Hearing Care $40 Copayment for Routine Hearing Exam $35
Hearing Aids: Coinsurance per aid 90%
|
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Preventive Care: Our plan covers many preventive services at no cost, including:
|
When reviewing Kentucky Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Kentucky that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Kentucky Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.