DEVOTED CHOICE GIVEBACK EXTRAS 012 MS (PPO)

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DEVOTED CHOICE GIVEBACK EXTRAS 012 MS (PPO) is a PPO plan offered by Devoted Health

Plan ID: H7355-012

HelpAdvisor Editorial Team analysis of data from the 2027 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as DEVOTED CHOICE GIVEBACK EXTRAS 012 MS (PPO) - H7355-012 by Devoted Health as well as other Medicare Advantage plans available in your area.

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Mississippi Counties Served

AttalaBentonCalhounClaiborneCopiahDesotoGeorgeGreeneHancockHarrisonHindsHolmesHumphreysIssaquenaJacksonLeakeMadisonMarshallNewtonPanolaPearl RiverPerryQuitmanRankinScottSharkeySmithStoneTateTippahTishomingoTunicaUnionWarrenYazoo

Basic Costs and Coverage

Coverage Cost
Drug Deductible $700
Out of Pocket Max In-Network: $7500
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $2100
Primary Care Doctor Visit
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $5
Specialty Doctor Visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $55
Cost share applies to wound care services and specialist services.
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$385 per day for days 1 to 7
$0 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Urgent Care
Urgent Care:
Copayment for Urgent Care $0 to $40

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 $115
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 $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $115
Copayment for Worldwide Emergency Transportation $355
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 to $355
Cost share applies per trip. Min cost share for facility to facility transfers. Max cost share for all other ambulance services.

Air Ambulance:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance
Cost share applies per trip.

Health Care Services and Medical Supplies

DEVOTED CHOICE GIVEBACK EXTRAS 012 MS (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $15
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 50%
  • Our preferred brand of blood glucose monitors is Accu-Chek.
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 50%

Dexcom Continuous Glucose Monitors (CGMs) and Supplies (Preferred):
Coinsurance when obtained at a retail pharmacy 50%
Coinsurance when obtained through a Durable Medical Equipment provider 50%

Non-Preferred CGMs and Supplies:
Coinsurance when obtained at a retail pharmacy 50%
  • Only FreeStyle Libre products are covered at retail pharmacies.
Coinsurance when obtained through a Durable Medical Equipment provider 50%

Please see the Evidence of Coverage for full glucose monitor benefit information.
Durable Medical Equipment (DME)
In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95
Copayment for Medicare-covered Lab Services $0 to $55
Coinsurance for Genetic Testing 20%
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
The min cost share applies to home sleep studies and other diagnostic tests at a PCP office or in the home. The mid cost share applies to EKGs/EEGs/ECGs at a PCP, specialist office, or freestanding facility and all other diagnostic tests at a specialist office or freestanding facility. The max cost share applies to EKGs/EEGs/ECGs and all other diagnostic tests at an outpatient hospital.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $25 to $300
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $75
Home Health Care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 40%
Mental Health Inpatient Care
Out-of-Network:

Psychiatric Hospital Services:
$385 per day for days 1 to 7
$0 per day for days 8 to 90
Mental Health Outpatient Care
In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $50
Copayment for Medicare-covered Group Sessions $50
Outpatient Services / Surgery
Out-of-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $485
Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $385
The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other outpatient hospital services.
Outpatient Substance Abuse Care
Out-of-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $55
Copayment for Medicare Covered Group Sessions $55
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $50
Copayment for Medicare-covered Group Sessions $50
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter (OTC) Items
Over-the-Counter Items (OTC):
$62 per quarter to use toward the purchase of eligible over-the-counter (OTC) items at participating locations. You get the most out of your OTC benefits when you shop at participating locations. If you purchase items at non-participating stores, you will be responsible for a 90% coinsurance.

Please see Evidence of Coverage for full benefit details.
Podiatry Services
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $55
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $55
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$221 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
Out-of-Network:

Medicare Covered Preventive Dental:
Copayment for office visit $55

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
Out-of-Network:

Medicare-Covered Vision Care:
Copayment for Medicare-Covered Diagnostic Eye Exams $55
Copayment for Diabetic Retinopathy Exams $0

Routine Vision Care:
Copayment for Routine Eye Exam $0
  • Limit 1 visit per year

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
Out-of-Network:

Hearing Exams:
Copayment for Medicare-covered Hearing Care $55
Copayment for Routine Hearing Exam $35
  • Maximum 1 visit every year
Copayment for Hearing Aid Fitting and Evaluation $35

Hearing Aids:
Coinsurance per aid 90%
  • Maximum 2 hearing aids per year
  • Please see Evidence of Coverage for full benefit details.

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
Preventive Care:
Our plan covers many preventive services at no cost, including:
  • Annual wellness visits
  • Bone mass measurements
  • Breast cancer screenings (mammograms)
  • Cardiovascular screenings
  • Cervical and vaginal cancer screenings
  • Colorectal cancer screenings
  • Diabetes screenings
  • Hepatitis B virus screenings
  • Prostate cancer screenings (PSA)
  • Vaccines (including Flu shots, Hepatitis B shots, Pneumococcal shots, and COVID shots)
Any additional preventive services approved by Medicare during the contract year will be covered. Our plan also covers certain preventive services more frequently than Medicare. Please see Summary of Benefits and Evidence of Coverage for full benefit information.

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