Devoted Health Latitude Manatee (PPO)

Devoted Health Latitude Manatee (PPO) H9884-007 Plan Details
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Devoted Health Latitude Manatee (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health.
Plan ID: H9884-007.

$0.00
Monthly Premium

Devoted Health Latitude Manatee (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health.
Plan ID: H9884-007.

Devoted Health Latitude Manatee (PPO) H9884-007 Plan Details
na

Devoted Health Latitude Manatee (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health.
Plan ID: H9884-007.

$0.00
Monthly Premium

Florida Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $150
Out of Pocket Max In-Network: $4900
Out-of-Network: 4900
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $0.00 to $30.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $0.00 to $30.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$295.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
$295.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Urgent Care
Copayment for Urgent Care $0.00 to $40.00

$0 PCP $40 Urgent Care Center

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $250.00
Coinsurance for Worldwide Emergency Transportation 20%
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Cost share applies per trip. Cost share does not apply for facility to facility transfers.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Devoted Health Latitude Manatee (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
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Copayment for Routine Care $20.00
  • Maximum 6 Routine Care every year
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $0.00 to $30.00 Copayment for Non-Medicare Covered Chiropractic Services $0.00 to $30.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
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)
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Diabetic Supplies and Services $0.00 to $30.00
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $25.00
Copayment for Medicare-covered Lab Services $0.00 to $25.00
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 $150.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $25.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0.00 to $25
Copayment for Medicare Covered Lab Services
$0.00 to $25
Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $150
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $25
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Home Health $0.00 to $30.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$295.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
$295.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $0.00 to $30.00
Copayment for Medicare Covered Group Sessions $0.00 to $30.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $295.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $295.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $150.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $295.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $295.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $0.00 to $30.00
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $60.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $60.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $30.00
Copayment for Routine Foot Care $30.00
  • Maximum 6 visits every year
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $0.00 to $30.00 Copayment for Non-Medicare Covered Podiatry Services $0.00 to $30.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$184.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
$0.00 per day for days 1 to 20
$184.00 per day for days 21 to 100

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Maximum Plan Allowance of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $30.00
Maximum Plan Allowance of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $0.00 to $30.00
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00
Maximum Plan Benefit of $1500.00

Vision Benefits

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

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $30.00
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 $1500.00 every year for all Non-Medicare covered eyewear
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00 to $30.00
Copayment for Medicare Covered Eyewear $0.00 to $30.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00 to $30.00
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

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

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30.00
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
Copayment Structure: Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearing's Advanced and Premium hearing aids, which come in various styles and colors. Plan will cover a hearing aid for a copay of $399 or $699, up to two hearing aids per year. Copay is determined by type of technology selected. Premium hearing aids are available in rechargeable style options for an additional $50 per aid. You must see a TruHearing provider to use this benefit. Hearing aid purchase includes: - First year of follow-up provider visits - 60-day trial period - 3-year extended warranty - 80 batteries per aid for non-rechargeable models Benefit does not include or cover any of the following: - Additional cost for optional hearing aid rechargeability - Ear molds - Hearing aid accessories - Additional provider visits - Additional batteries, batteries when a rechargeable hearing aid is purchased - Hearing aids that are not Tr
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $0.00 to $30.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00 to $30.00
Copayment for Non-Medicare Covered Hearing Aids $399.00 to $699.00

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
In-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
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 to $30.00

    Prescription Drug Costs and Coverage

    The Devoted Health Latitude Manatee (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $150 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $150 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $150 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $0.00
    • Standard mail order $0.00