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Devoted CHOICE GIVEBACK Polk (PPO) - H9884-006-000
$0.00
Monthly Premium
Devoted CHOICE GIVEBACK Polk (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H9884-006-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Florida 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 Florida 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 | $150.00 |
| Out-of-pocket maximum | $5,500.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $30.00 |
| Inpatient hospital care | Out-of-Network: $295.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
| Urgent care | Urgent Care: Copayment for Urgent Care $0.00 to $50.00 $0 PCP $50 Urgent Care Center Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $250.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
Devoted CHOICE GIVEBACK Polk (PPO) covers a range of additional benefits. Learn more about Devoted CHOICE GIVEBACK Polk (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 $20.00 Chiropractic Services: Copayment for Non-Medicare Covered Chiropractic Services $20.00 |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 40% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage |
| 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 $175.00 Copayment for Medicare Covered Lab Services $0.00 to $40.00 Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $150.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $150.00 |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental health inpatient care | Out-of-Network: $295.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $30.00 Copayment for Medicare Covered Group Sessions $30.00 |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $295.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $150.00 |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $30.00 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $45.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $30.00 |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Coinsurance for Skilled Nursing Facility Services 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: Preventive Dental: Maximum Plan Allowance of $1250.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $30.00 Maximum Plan Allowance of $1250.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined |
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: Eye Exams: Copayment for Medicare Covered Benefits $30.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $1250.00 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 care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $30.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for 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 Polk (PPO) offers prescription drug coverage, with an annual drug deductible of $150.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $150.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $150.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $150.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Florida 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 Florida that offer similar benefits at similar or lower prices than the plan above. Call 1-877-890-1409 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Florida Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.