Devoted CHOICE GIVEBACK Tampa (PPO)

Plan too new to be measured* for plan year 2023
$0.00 Monthly Premium

Devoted CHOICE GIVEBACK Tampa (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health

Plan ID: H9884-005-000

$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$7,400.00
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 $60.00
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 $40.00

$0 PCP
$40 Urgent Care Center

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $250.00
Coinsurance for Worldwide Emergency Transportation 20%
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Devoted CHOICE GIVEBACK Tampa (PPO) covers a range of additional benefits. Learn more about Devoted CHOICE GIVEBACK Tampa (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Copayment for Routine Care $20.00
  • Maximum 6 Routine Care every year
Diabetes supplies, training, nutrition therapy and monitoringIn-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 50%
Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
40%
Coinsurance for Medicare Covered Lab Services
40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
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 careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered 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 $90.00 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 $60.00
Podiatry Services:
Copayment for Non-Medicare Covered Podiatry Services $60.00
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$184.00 per day for days 21 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 careIn-Network:

Preventive Dental:
Maximum Plan Allowance of $1250.00 every year 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 Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefitsIn-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

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
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $60.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $60.00
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 Tampa (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

    Hernando Hillsborough Pasco Pinellas
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