DEVOTED DUAL CHOICE FULL 012 AL (PPO D-SNP)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0

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.

Out-of-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0

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 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.

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.

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0

• Our preferred brand of blood glucose monitors is Accu-Chek.

Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $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

• Only FreeStyle Libre products are covered at retail pharmacies.

Copayment when obtained through a Durable Medical Equipment provider $0

Please see the Evidence of Coverage for full glucose monitor benefit information.

In-Network:

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior Authorization Required for Durable Medical Equipment

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.

Out-of-Network:

Home Health Services:
Copayment for Medicare Covered Home Health $0

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization Required for Psychiatric Hospital Services

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0

Out-of-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Copayment for Medicare Covered Ambulatory Surgical Center Services $0
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.

In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

Out-of-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $0
Copayment for Medicare Covered Group Sessions $0

Over-the-Counter Items (OTC):
$40 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.

In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Copayment for Routine Foot Care $0

• Maximum 6 visits every year

Prior Authorization Required for Podiatry Services

Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $0

Out-of-Network:

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility per Stay $0

In-Network:

Medicare Covered Preventive Dental:
Copayment for office visit $0
Prior Authorization may be required.

Non-Medicare Covered Dental Services:
Devoted Health will pay as much as $3,500 per year for covered dental services. You pay $0 towards all covered dental services until you reach your plan's dollar limit. For any services received after you reach your plan's dollar limit, you'll pay the full cost.

Covered dental services are limited to specific dental codes as listed in your Evidence of Coverage, and include, but are not limited to: periodic oral exams, dental evaluations, cleanings, X-rays, fillings, deep cleanings, extractions, dentures, root canals, crowns, and bridges. Cosmetic procedures, dental implants, and/or elective procedures are not covered. See your Evidence of Coverage for a full list of covered services and coverage limitations.

Non-Medicare Covered Preventive Dental:
Maximum plan benefit of $3,500 per year. Please see Evidence of Coverage for dental code restrictions and frequency limitations.
Copayment for Oral exams $0
Copayment for Dental x-rays $0
Copayment for Prophylaxis (cleanings) $0
Copayment for Fluoride treatment $0

Non-Medicare Covered Comprehensive Dental:
Maximum plan benefit of $3,500 per year. Please see Evidence of Coverage for dental code restrictions and frequency limitations.
Copayment for Restorative services (e.g. fillings, crowns) $0
Copayment for Endodontics (e.g. root canal) $0
Copayment for Periodontics (e.g. scaling, root planing) $0
Copayment for Prosthodontics, removable (e.g. dentures) $0
Copayment for Prosthodontics, fixed (e.g. bridges) $0
Copayment for Maxillofacial surgery (e.g. extractions) $0
Copayment for Adjunctive general services $0

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

• Limit 1 visit per year

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.

Out-of-Network:

Hearing Exams:
Copayment for Medicare-covered Hearing Care $0
Copayment for Routine Hearing Exam $0

• Maximum 1 visit every year

Copayment for Hearing Aid Fitting and Evaluation $0

Hearing Aids:
Coinsurance per aid 90%

• Maximum 2 hearing aids per year
• Please see Evidence of Coverage for full benefit details.

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.