Devoted CHOICE GIVEBACK Hawaii (PPO)
Devoted CHOICE GIVEBACK Hawaii (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H2686-003-000
Hawaii 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 extra benefits Original Medicare doesn’t cover.
Learn more about Hawaii 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 | $545.00 |
| Out-of-pocket maximum | $8,300.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $50.00 |
| Inpatient hospital care | Out-of-Network: $475.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 |
| Urgent care | Urgent Care: Copayment for Urgent Care from PCP $0.00 Copayment for Urgent Care from Urgent Care Center $55.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $295.00 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $295.00 Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
Devoted CHOICE GIVEBACK Hawaii (PPO) covers a range of additional benefits. Learn more about Devoted CHOICE GIVEBACK Hawaii (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 $15.00 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 0% to 35% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $100.00 Copayment for Medicare Covered Lab Services $0.00 Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $250.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $100.00 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | Out-of-Network: $475.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $45.00 Copayment for Medicare Covered Group Sessions $45.00 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $400.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $475.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $350.00 Prior Authorization Required for Ambulatory Surgical Center Services Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $400.00 Copayment for Medicare Covered Observation Services - Per stay $475.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $350.00 |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $45.00 |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $50.00 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $200.00 per day for days 21 to 61 $0.00 per day for days 62 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
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: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $50.00 Copayment for Diagnostic Services $0.00
Prior Authorization Required for Comprehensive Dental Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $50.00 Non-Medicare Covered Dental Services: Copay for Non-Medicare Covered Preventive Dental $0 Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 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 benefits | In-Network: Eye Exams: Copayment for Medicare Covered Eye Exams $50.00 Copayment for Routine Eye Exams $0.00
Eyewear: Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Out-of-Network: Eye Exams: Copayment for Medicare Covered Eye Exams $50.00 Copayment for Non-Medicare Covered Routine Eye Exams $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $50.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $399.00 to $699.00
Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $50.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Hearing Aids: Copayment for Non-Medicare Covered Hearing Aids $399.00 to $699.00 |
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 | Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
Prescription Drug Costs and Coverage
The Devoted CHOICE GIVEBACK Hawaii (PPO) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tiers 1 and 2)
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual drug deductible | $545.00 (excludes Tiers 1 and 2) |
| Tier 1 | |
| Tier 2 | |
| Annual drug deductible | $545.00 (excludes Tiers 1 and 2) |
| Tier 1 | |
| Tier 2 | |
| Annual drug deductible | $545.00 (excludes Tiers 1 and 2) |
| Tier 1 | |
| Tier 2 | |
When reviewing Hawaii 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 Hawaii 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 |
Hawaii Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
