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DEVOTED CHOICE GIVEBACK EXTRAS 026 IN (PPO) - H7471-026-000
$0.00
Monthly Premium
DEVOTED CHOICE GIVEBACK EXTRAS 026 IN (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H7471-026-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Indiana 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 Indiana 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 | $700.00 |
| Out-of-pocket maximum | $7,500.00 |
| 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 $45 Cost share applies to wound care services and specialist services. |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: $490 per day for days 1 to 5 $0 per day for days 6 to 90 |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 to $40 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 $115 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 $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $115 Copayment for Worldwide Emergency Transportation $335 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 $335 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 GIVEBACK EXTRAS 026 IN (PPO) covers a range of additional benefits. Learn more about DEVOTED CHOICE GIVEBACK EXTRAS 026 IN (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 | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0
Dexcom Continuous Glucose Monitors (CGMs) and Supplies (Preferred): Copayment when obtained at a retail pharmacy $0 Coinsurance when obtained through a Durable Medical Equipment provider 20% Non-Preferred CGMs and Supplies: Coinsurance when obtained at a retail pharmacy 20%
Please see the Evidence of Coverage for full glucose monitor benefit information. |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare-covered Lab Services $0 to $45 Coinsurance for Genetic Testing 20% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services 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. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $25 to $300 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $75 |
| 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: $455 per day for days 1 to 4 $0 per day for days 5 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 $45 Copayment for Medicare Covered Group Sessions $45 |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $555 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $455 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 substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $45 Copayment for Medicare Covered Group Sessions $45 |
| Over-the-counter items | Over-the-Counter Items (OTC): $177 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 | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45 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 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 | Out-of-Network: Medicare Covered Preventive Dental: Copayment for office visit $45 |
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 | In-Network: Medicare-Covered Vision Care: Copayment for Medicare-Covered Diagnostic Eye Exams $45 Copayment for Diabetic Retinopathy Exams $0 Prior authorization may be required. Routine Vision Care: Copayment for Routine Eye Exam $0
Eyewear: Up to $350 each year for eyeglasses and/or contacts You can visit any eyewear provider, in-network or out-of-network. Please see the Evidence of Coverage for full benefit details. |
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 | In-Network: Hearing Exams: Copayment for Medicare-covered Hearing Care $45 Copayment for Routine Hearing Exam $0
Prior Authorization may be required. Hearing Aids: Copayment per aid $599 to $899
|
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 Indiana 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 Indiana 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 |
Indiana Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.