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Do you have Medicaid? View Dual HMO Plan

Devoted CHOICE Colorado (PPO)
Devoted CHOICE GIVEBACK Colorado (PPO)
Devoted GIVEBACK Colorado (HMO-POS)
Devoted CORE Colorado (HMO-POS)

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Devoted CHOICE Colorado (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CHOICE GIVEBACK Colorado (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted GIVEBACK Colorado (HMO-POS)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE Colorado (HMO-POS)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

You must continue to pay your part B premium.

$0

Also, your Part B premium is reduced by up to $130 per month.

$0

Also, your Part B premium is reduced by up to $115 per month.

$0

You must continue to pay your part B premium.

Part B Giveback

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

None

Up to $130 per month

Up to $115 per month

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:

  • $5,500


In- and Out-of-network:

  • $8,950

In-network:

  • $7,900


In- and Out-of-network:

  • $10,000

$5,900

$3,900

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*

$0 copay*

Specialist Visits

In-network:

  • $25 copay*


Out-of-network:

  • $25 copay

In-network:

  • $50 copay*


Out-of-network:

  • $50 copay

$40 copay*

$20 copay*

Inpatient Hospital Stays

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

In-network:

  • Days 1 - 5
    $385 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $385 copay per day

    Day 6+
    $0 copay per day

Days 1 - 6
$350 copay per day

Day 7+
$0 copay per day*

Days 1 - 5
$225 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:

  • $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

In-network:

  • $325 copay* at an ambulatory surgery center
  • $350 copay* at an outpatient hospital


Out-of-network:

  • $325 copay at an ambulatory surgery center
  • $350 copay at an outpatient hospital

  • $250 copay* at an ambulatory surgery center
  • $300 copay* at an outpatient hospital

  • $125 copay* at an ambulatory surgery center
  • $200 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.

$120 copay per stay

$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.

$45 copay

$55 copay

$50 copay

$30 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*


Out-of-network:

  • $0 copay

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

$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*
  • $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

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

  • $0 copay in an office or freestanding location*
  • $25 copay at an outpatient hospital setting*

  • $0 copay in an office or freestanding location*
  • $15 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*
  • $25 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $25 copay at an outpatient hospital setting

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

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

  • $0 copay in an office or freestanding location*
  • $25 copay at an outpatient hospital setting*

Pharmacy (Part D) Deductible

This plan does not have a 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.

$150 for Tiers 4-5 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.

30-Day Supply Retail Pharmacy

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

  • 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

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $95 per prescription
  • Tier 5: 25% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $9 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $95 per prescription
  • Tier 5: 30% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $95 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: $0 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: $285 per prescription
  • Tier 5: Not available through mail

  • Tier 1: $0 per prescription
  • Tier 2: $22.50 per prescription
  • Tier 3: $117.50 per prescription
  • Tier 4: $285 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: $285 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.

$0 per prescription*

$5 per prescription*

$9 per prescription*

$0 per prescription*

Dental

  • Free preventive care
  • $4,000 per year toward comprehensive dental


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

$1,000 a year for all covered dental services

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

$1,000 a year for all covered dental services

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

  • Free preventive care
  • $4,000 per year toward comprehensive dental


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

Food & Home Card

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

$60 per month

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

Not covered

Not covered

$60 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

$35 per quarter (every 3 months)

Not covered

Not covered

$50 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*

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*

  • $599 copay per ear for Advanced Aids*
  • $899 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

$300 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

$200 per year toward glasses or contacts

  • $0 copay for yearly routine eye exam*
  • $200 toward glasses or contacts
  • Free contact lens fitting

  • $0 copay for yearly routine eye exam*
  • $400 toward glasses or contacts
  • Free contact lens fitting

Fitness

  • Free SilverSneakers membership*
  • $300 per year to spend on fitness trackers, home gym equipment, and more

  • Free SilverSneakers membership*
  • $300 per year to spend on fitness trackers, home gym equipment, and more

  • Free SilverSneakers membership*
  • $300 per year to spend on fitness trackers, home gym equipment, and more

  • Free SilverSneakers membership*
  • $300 per year to spend on fitness trackers, home gym equipment, and more

Naturopath Services

Office visits to a Naturopath. Covered services do not include herbs, homeopathic remedies, medications and nutritional supplements, vitamins or vitamin injections.

$300 per year

This is part of your Wellness Bucks benefit.

$300 per year

This is part of your Wellness Bucks benefit.

$300 per year

This is part of your Wellness Bucks benefit.

$300 per year

This is part of your Wellness Bucks benefit.

Routine Acupuncture

This goes beyond Medicare's benefit, which covers treatment only for chronic lower back pain.

$300 per year

This is part of your Wellness Bucks benefit.

$300 per year

This is part of your Wellness Bucks benefit.

$300 per year

This is part of your Wellness Bucks benefit.

$300 per year

This is part of your Wellness Bucks benefit.

*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.