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Devoted CHOICE GIVEBACK Polk (PPO) - H9884-006-000

Not enough data available* for plan year 2024

$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

CoverageDetails
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 visitIn-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 transportationIn-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).

CoverageDetails
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 itemsIn-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.

CoverageDetails
Dental careIn-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

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

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.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $399.00 to $699.00
  • Maximum 2 Hearing Aids every year

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.

CoverageDetails
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
  • Standard retail $0.00
  • Standard mail order $0.00
Tier 2
  • Standard retail $0.00
  • Standard mail order $0.00
Annual drug deductible$150.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
Tier 2
  • Standard retail $0.00
  • Standard mail order $0.00
Annual drug deductible$150.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
Tier 2
  • Standard retail $0.00
  • Standard mail order $0.00

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 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Florida Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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