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Devoted CHOICE GIVEBACK Tennessee (PPO)
Devoted CHOICE Tennessee (PPO)
Devoted CORE Tennessee (HMO)

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Devoted CHOICE GIVEBACK Tennessee (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CHOICE Tennessee (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE Tennessee (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

Also, your Part B premium is reduced by up to $155 per month.

$0

You must continue to pay your part B premium.

$0

You must continue to pay your part B premium.

Part B Giveback

This amount goes back into your Social Security check each month.

Up to $155 per month

None

None

Annual Out-of-Pocket Maximum

This is the most you'll pay in a year for Medicare covered medical services. Your out-of-pocket Part D drug costs don't count toward this amount.

In-network:

  • $8,300


In- and Out-of-network:

  • $10,000

In-network:

  • $5,500


In- and Out-of-network:

  • $8,950

$4,500

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

$0 copay*

Specialist Visits

In-network:

  • $50 copay*


Out-of-network:

  • $50 copay

In-network:

  • $30 copay*


Out-of-network:

  • $30 copay

$20 copay*

Inpatient Hospital Stays

In-network:

  • Days 1 - 4
    $475 copay per day

    Day 5+
    $0 copay per day*


Out-of-network:

  • Days 1 - 4
    $475 copay per day

    Day 5+
    $0 copay per day

In-network:

  • Days 1 - 5
    $295 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $295 copay per day

    Day 6+
    $0 copay per day

Days 1 - 5
$295 copay per day

Day 6+
$0 copay per day*

Outpatient Surgery

Ambulatory surgery centers are different from hospitals and focus just on outpatient surgery.

In-network:

  • $350 copay* at an ambulatory surgery center
  • $400 copay* at an outpatient hospital


Out-of-network:

  • $350 copay at an ambulatory surgery center
  • $400 copay at an outpatient hospital

In-network:

  • $200 copay* at an ambulatory surgery center
  • $250 copay* at an outpatient hospital


Out-of-network:

  • $200 copay at an ambulatory surgery center
  • $250 copay at an outpatient hospital

  • $175 copay* at an ambulatory surgery center
  • $225 copay* at an outpatient hospital

Emergency Room Visit

If admitted to the hospital within 24 hours, you won't have a copay for emergency care.

$100 copay per stay

$120 copay per stay

$120 copay per stay

Urgent Care Center Visit

To treat a non-emergency illness, injury, or condition that requires immediate medical care.

$55 copay

$40 copay

$40 copay

Labs

If the lab is part of a hospital system, you might pay the higher copay. Call us to find out.

In-network:

    • $0 copay in an office or freestanding location*
    • $40 copay at an outpatient hospital setting*
    *


Out-of-network:

    • $0 copay in an office or freestanding location
    • $40 copay at an outpatient hospital setting

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

$0 copay*

X-rays and Ultrasounds

If the provider is part of a hospital system, you might pay the higher copay. Call us to find out.

In-network:

  • $0 copay in an office or freestanding location*
  • $100 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $100 copay at an outpatient hospital setting

In-network:

  • $0 copay in an office or freestanding location*
  • $15 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $15 copay at an outpatient hospital setting

  • $0 copay in an office or freestanding location*
  • $20 copay at an outpatient hospital setting*

Diagnostic Tests and Procedures

If the provider is part of a hospital system, you might pay the higher copay. Call us to find out.

In-network:

  • $0 copay in an office or freestanding location*
  • $100 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $100 copay at an outpatient hospital setting

In-network:

  • $0 copay in an office or freestanding location*
  • $20 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $20 copay at an outpatient hospital setting

  • $0 copay in an office or freestanding location*
  • $20 copay at an outpatient hospital setting*

Pharmacy (Part D) Deductible

$545 for Tiers 3-5 only

If you receive "Extra Help" from Medicare, your deductible will be $0.

The deductible does not apply to covered Part D insulins and most adult Part D vaccines.

This plan does not have a deductible.

This plan does not have a deductible.

30-Day Supply Retail Pharmacy

If you get Extra Help from Medicare, your costs may be lower.

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 25% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 33% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 33% of the total cost

100-Day Supply Mail-Order Pharmacy

If you get Extra Help from Medicare, your costs may be lower.

  • Tier 1: $0 per prescription
  • Tier 2: $12.50 per prescription
  • Tier 3: $117.50 per prescription
  • Tier 4: $300 per prescription
  • Tier 5: Not available through mail

  • Tier 1: $0 per prescription
  • Tier 2: $12.50 per prescription
  • Tier 3: $117.50 per prescription
  • Tier 4: $300 per prescription
  • Tier 5: Not available through mail

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: $117.50 per prescription
  • Tier 4: $300 per prescription
  • Tier 5: Not available through mail

Erectile Dysfunction Drugs

Sildenafil (Viagra) and tadalfil (Cialis) are covered medications for up to 6 pills a month.

$5 per prescription*

$5 per prescription*

$0 per prescription*

Dental

$1,000 a year for all covered dental services

This plan also includes out-of-network dental coverage.

  • Free preventive care
  • $3,500 per year toward comprehensive dental


This plan also includes out-of-network dental coverage.

  • Free preventive care
  • $5,000 per year toward comprehensive dental

Food & Home Card

Pre-loaded card for purchase of groceries, utilities, mortgage, or rent

Not covered

$50 per month

The Food & Home Card is available to members with eligible chronic health conditions.

$85 per month

The Food & Home Card is available to members with eligible chronic health conditions.

Over-the-Counter Credit

For items like toothpaste, vitamins, blood pressure cuffs, and more

Not covered

$95 per quarter (every 3 months)

$75 per quarter (every 3 months)

Medical Alert Device

Call for emergency help with the press of a button.

Free device and free monthly monitoring*

Free device and free monthly monitoring*

Free device and free monthly monitoring*

Hearing Aids

Plan covers 2 hearing aids a year, plus free batteries.

  • $399 copay per ear for Advanced Aids*
  • $699 copay per ear for Premium Aids*

  • $399 copay per ear for Advanced Aids*
  • $699 copay per ear for Premium Aids*

  • $399 copay per ear for Advanced Aids*
  • $699 copay per ear for Premium Aids*

Vision

In-network:

  • $0 copay for yearly routine eye exam*
  • Free contact lens fitting

Out-of-network:

  • $0 copay for yearly routine eye exam

$200 per year toward glasses or contacts

In-network:

  • $0 copay for yearly routine eye exam*
  • Free contact lens fitting

Out-of-network:

  • $0 copay for yearly routine eye exam

$250 per year toward glasses or contacts

  • $0 copay for yearly routine eye exam*
  • $300 toward glasses or contacts
  • Free contact lens fitting

Fitness

  • Free SilverSneakers membership*
  • $150 per year to spend on fitness trackers, home gym equipment, and more

  • Free SilverSneakers membership*
  • $150 per year to spend on fitness trackers, home gym equipment, and more

  • Free SilverSneakers membership*
  • $150 per year to spend on fitness trackers, home gym equipment, and more

*When you use an in-network provider or pharmacy.


Next Steps

Now that you know what our plans are all about, you can:

And if you have any questions, call us at (1-800-990-0723) (TTY 711) You can also see and compare more plan options at www.Medicare.gov.