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DEVOTED DUAL CHOICE QMB 026 LA (PPO D-SNP) - H7766-026-000
$0.00
Monthly Premium
DEVOTED DUAL CHOICE QMB 026 LA (PPO D-SNP) is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H7766-026-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Louisiana 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 additional benefits Original Medicare doesn’t cover.
Learn more about Louisiana 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 | $700.00 |
| Out-of-pocket maximum | $9,850.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $0 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $0 Cost share applies to wound care services and specialist services. |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 The min cost share applies to urgently needed services received by a PCP. The max cost share applies to urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $0 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation $0 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Ambulance transportation | Ground Ambulance: Copayment for Ground Ambulance Services $0 Air Ambulance: Copayment for Air Ambulance Services $0 Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED DUAL CHOICE QMB 026 LA (PPO D-SNP) covers a range of additional benefits. Learn more about DEVOTED DUAL CHOICE QMB 026 LA (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0
Dexcom Continuous Glucose Monitors (CGMs) and Supplies (Preferred): Copayment when obtained at a retail pharmacy $0 Copayment when obtained through a Durable Medical Equipment provider $0 Non-Preferred CGMs and Supplies: Copayment when obtained at a retail pharmacy $0
Please see the Evidence of Coverage for full glucose monitor benefit information. |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0 Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Diagnostic Procedures/Tests Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 Copayment for Medicare-covered Lab Services $0 Copayment for Medicare-covered Diagnostic Radiological Services $0 Copayment for Medicare-covered Therapeutic Radiological Services $0 Copayment for Medicare-covered Outpatient X-Ray Services $0 The min cost share applies to home sleep studies and other diagnostic tests at a PCP office or in the home. The max cost share applies to EKGs/EEGs/ECGs at all sites of service and all other diagnostic tests at a specialist office, freestanding facility, or an outpatient hospital. |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital per Stay $0 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 Prior Authorization Required for Outpatient Hospital Services The min cost share applies to screening colonoscopies that become diagnostic. The max cost share applies to diagnostic colonoscopies and to all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to screening colonoscopies that become diagnostic. The max cost share applies to diagnostic colonoscopies and all other ASC services. |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $0 Copayment for Medicare Covered Group Sessions $0 |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $0 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $0 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 care | Out-of-Network: Medicare Covered Preventive Dental: Copayment for office visit $0 Non-Medicare Covered Dental Services: If you choose to see an out-of-network dentist, you will be responsible for paying the difference between the rate we pay the dentist and the rate your dental provider charges, even if you have not yet reached your plan's dollar limit. Please see Evidence of Coverage for full benefit details. |
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: Medicare-Covered Vision Care: Copayment for Medicare-Covered Diagnostic Eye Exams $0 Copayment for Diabetic Retinopathy Exams $0 Prior authorization may be required. Routine Vision Care: Copayment for Routine Eye Exam $0
Eyewear: Up to $400 each year for eyeglasses and/or contacts You can visit any eyewear provider, in-network or out-of-network. Please see the Evidence of Coverage for full benefit details. |
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 | Out-of-Network: Hearing Exams: Copayment for Medicare-covered Hearing Care $0 Copayment for Routine Hearing Exam $0
Hearing Aids: Coinsurance per aid 90%
|
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 | Preventive Care: Our plan covers many preventive services at no cost, including:
|
When reviewing Louisiana 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 Louisiana 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 |
Louisiana Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.