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Devoted CHOICE Hawaii (PPO) - H2686-001-000

Plan too new to be measured* for plan year 2024

$0.00

Monthly Premium

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

Plan ID: H2686-001-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

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

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$200.00
Out-of-pocket maximum$6,700.00
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 visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35.00
Inpatient hospital care
Out-of-Network:
$375.00 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 $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 $220.00
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $220.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
Please see Evidence of Coverage for Prior Authorization rules

Out-of-Network:

Ground Ambulance:

Copayment for Ground Ambulance Services $220.00


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

CoverageDetails
Chiropractic servicesChiropractic Services:
In-Network:
Copayment for Medicare-covered Chiropractic Services $15.00
Copayment for Routine Care $15.00
  • Maximum 12 Routine Care every year

Out-of-Network:

Copayment for Medicare-covered Chiropractic Services $15.00

Copayment for Routine Care $15.00

  • Maximum 12 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 0% to 40%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $110.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$375.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care
Out-of-Network:

Outpatient Mental Health Services:
Copayment for Medicare Covered Individual Sessions $35.00
Copayment for Medicare Covered Group Sessions $35.00
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $350.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $300.00
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $95.00 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 $35.00
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:

Preventative Dental:

Preventative dental services may be covered at $0 copay for services such as exams, evaluations, cleanings, and x-rays.

See the plan's Evidence of Coverage (EOC) for more details. Certain limitations apply. This is not an exhaustive list of covered dental services.
Copay for Comprehensive Dental Services $0

  • Fillings
  • Deep Cleaning
  • Extractions
  • Dentures
  • Root Canals
  • Crowns
  • Bridges
(Please see Evidence of Coverage for details)
Maximum Plan Benefit of $5000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental

Out-of-Network:

Preventative Dental:

Preventative dental services may be covered at $0 copay for services such as exams, evaluations, cleanings, and x-rays.

See the plan's Evidence of Coverage (EOC) for more details. Certain limitations apply. This is not an exhaustive list of covered dental services.

Coinsurance for Comprehensive Dental Services 50%

  • Fillings
  • Deep Cleaning
  • Extractions
  • Dentures
  • Root Canals
  • Crowns
  • Bridges

(Please see Evidence of Coverage for details)

Maximum Plan Benefit of $5000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive

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

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $35.00
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 $300.00 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 $35.00
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 programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Devoted CHOICE Hawaii (PPO) offers prescription drug coverage, with an annual drug deductible of $200.00 (excludes Tiers 1 and 2)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$200.00 (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$200.00 (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$200.00 (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 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.

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