DEVOTED GIVEBACK EXTRAS 015 NM (HMO)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45
Prior Authorization Required for Doctor Specialty Visit
Cost share applies to wound care services and specialist services.

In-Network:

Acute Hospital Services:
$550 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $0 to $50

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 $130
Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details.

Emergency Care:
Copayment for Emergency Care $130
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $130
Copayment for Worldwide Emergency Transportation $345
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 to $345
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.

In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services

In-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
Coinsurance when obtained through a Durable Medical Equipment provider 17%

Non-Preferred CGMs and Supplies:
Coinsurance when obtained at a retail pharmacy 17%

• Only FreeStyle Libre products are covered at retail pharmacies.

Coinsurance when obtained through a Durable Medical Equipment provider 17%

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

In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 17%
Prior Authorization Required for Durable Medical Equipment

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 $45
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

In-Network:

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

In-Network:

Psychiatric Hospital Services:
$425 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $45
Copayment for Medicare-covered Group Sessions $45

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $525
Prior Authorization Required for Outpatient Hospital Services
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 Observation Services:
Copayment for Medicare Covered Observation Services - Per day $425
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $425
Prior Authorization Required for Ambulatory Surgical Center Services
The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other ASC services.

In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $45
Copayment for Medicare-covered Group Sessions $45
Prior Authorization Required for Outpatient Substance Abuse Services

Over-the-Counter Items (OTC):
$184 per quarter to use toward the purchase of eligible over-the-counter (OTC) items at participating locations.

Please see Evidence of Coverage for full benefit details.

In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45
Prior Authorization Required for Podiatry Services

In-Network:

Skilled Nursing Facility Services:
$10 per day for days 1 to 20
$221 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

In-Network:

Medicare Covered Preventive Dental:
Copayment for office visit $45
Prior Authorization may be required.

Dental Allowance:
You have a $3,000 yearly allowance toward Preventive Dental and Comprehensive Dental. You can see any licensed dentist in the United States.

You will pay the costs yourself at first. Then, you can submit a request for reimbursement to Devoted.

For all covered preventive dental services, like exams and routine cleanings, you will receive 100% reimbursement up to the yearly allowance.

For all covered comprehensive dental services, you will receive 50% reimbursement up to the yearly allowance.

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 Dental Allowance of $3,000 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 Dental Allowance of $3,000 per year. Please see Evidence of Coverage for dental code restrictions and frequency limitations.
Coinsurance for Restorative services (e.g. fillings, crowns) 50%
Coinsurance for Endodontics (e.g. root canal) 50%
Coinsurance for Periodontics (e.g. scaling, root planing) 50%
Coinsurance for Prosthodontics, removable (e.g. dentures) 50%
Coinsurance for Prosthodontics, fixed (e.g. bridges) 50%
Coinsurance for Maxillofacial surgery (e.g. extractions) 50%
Coinsurance for Adjunctive general services 50%

In-Network:

Medicare-Covered Vision Care:
Copayment for Medicare-Covered Diagnostic Eye Exams $45
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 must use our designated vendor for this benefit. Please see the Evidence of Coverage for full benefit details.

In-Network:

Hearing Exams:
Copayment for Medicare-covered Hearing Care $45
Copayment for Routine Hearing Exam $0

• Maximum 1 visit every year

Copayment for Hearing Aid Fitting and Evaluation $0
Prior Authorization may be required.

Hearing Aids:
Copayment per aid $599 to $899

• Maximum 2 TruHearing 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.