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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.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $375.00 |
| Out-of-pocket maximum | $5,700.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $40 Cost share applies to wound care services, facet injections, cortisol injections, and specialist services. |
| Inpatient hospital care | In-Network: Acute Hospital Services: $325 per day for days 1 to 7 $0 per day for days 8 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 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $130 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation (Ground) $315 Maximum Plan Benefit of $25,000 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 to $315 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 | Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 29% |
| 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 $20 Coinsurance for Medicare Covered Lab Services 20% Copayment for Medicare Covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Copayment for Medicare Covered Outpatient X-Ray Services $0 to $75 Cost share varies based on site of service:PCPs office: No cost share for EKGs/EEGs/ECGs, no cost share all other. Specialist office: No cost share for EKGs/EEGs/ECGs, $40 copay all other. Freestanding facility: $40 copay for EKGs/EEGs/ECGs, $40 copay all other. Outpatient hospital: $95 copay for EKGs/EEGs/ECGs, $95 copay all other. No cost share for home sleep studies. No cost share for remote patient monitoring services. |
| 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: $325 per day for days 1 to 7 $0 per day for days 8 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 $425 Prior Authorization Required for Outpatient Hospital Services The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $325 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $325 Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to diagnostic colonoscopies, 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 | Out-of-Network: Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0 Maximum Plan Benefit of $100 |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 29% |
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 | Medicare Covered Preventive Dental: Copayment for Office Visit $40 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Dental Services: This plan has a Dental Allowance with Partial Comprehensive Dental Costshare: You have a $3,500 yearly allowance toward preventive and comprehensive dental. You can see any licensed dentist in the United States. You will pay the costs yourself at first and then submit a request for reimbursement to Devoted. For dentures, crowns, root canals, and bridges, a 50% coinsurance applies, with reimbursement up to the $3,500 yearly allowance. For all other covered services, you will receive 100% reimbursement up to the $3,500 yearly allowance. Cosmetic procedures, dental implants, and/or elective procedures are not covered. Non-Medicare Covered Preventive Dental: Maximum dental allowance of $3,500 every year
Maximum dental allowance of $3,500 every year
|
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: Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 to $40 Copayment for Medicare Covered Eyewear $0 The min cost share applies to diabetic retinopathy exams. The max cost share applies to other Medicare-covered eye exams. |
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 Services: Copayment for Medicare Covered Hearing Exams $40 |
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 | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The DEVOTED CHOICE 003 KY (PPO) offers prescription drug coverage, with an annual drug deductible of $375.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $375.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $375.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $375.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
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 1-855-861-8771 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, Healthspring, Wellcare, or Kaiser Permanente.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.