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Devoted CHOICE Ohio (PPO)
Devoted GIVEBACK Ohio (HMO)
Devoted CORE Ohio (HMO)
Devoted PRIME Ohio (HMO)

Want help enrolling? Give us a call.

1-800-990-0723 (TTY 711)

Devoted CHOICE Ohio (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted GIVEBACK Ohio (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE Ohio (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted PRIME Ohio (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023
Join CHOICE (PPO)
Join GIVEBACK (HMO)
Join CORE (HMO)
Join PRIME (HMO)

2024 CMS Plan Rating

Every year, Medicare evaluates plans based on a 5-star rating system.

CMS Rating not applicable

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Monthly Premium

$0

You must continue to pay your part B premium.

$0

Also, your Part B premium is reduced by up to $164.90 per month.

$0

You must continue to pay your part B premium.

$14

You must continue to pay your part B premium.

If you receive "Extra Help" from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium may be reduced to $0.

Part B Giveback

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

None

Up to $164.90 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:

  • $5,300


In- and Out-of-network:

  • $5,300

$5,900

$3,800

$3,900

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

$0 copay*

$0 copay*

$0 copay*

Specialist Visits

In-network:

  • $30 copay*


Out-of-network:

  • $30 copay

$40 copay*

$25 copay*

$25 copay*

Inpatient Hospital Stays

In-network:

  • Days 1 - 5
    $395 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $395 copay per day

    Day 6+
    $0 copay per day

Days 1 - 5
$450 copay per day

Day 6+
$0 copay per day*

Days 1 - 6
$295 copay per day

Day 7+
$0 copay per day*

Days 1 - 6
$295 copay per day

Day 7+
$0 copay per day*

Outpatient Surgery

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

In-network:

  • $300 copay* at an ambulatory surgery center
  • $350 copay* at an outpatient hospital


Out-of-network:

  • $300 copay at an ambulatory surgery center
  • $350 copay at an outpatient hospital

  • $250 copay* at an ambulatory surgery center
  • $450 copay* at an outpatient hospital

  • $195 copay* at an ambulatory surgery center
  • $295 copay* at an outpatient hospital

  • $100 copay* at an ambulatory surgery center
  • $295 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

$120 copay per stay

$135 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

$50 copay

$35 copay

$25 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

$0 copay*

$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*
  • $50 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $50 copay at an outpatient hospital setting

  • $0 copay in an office*
  • $50 copay at a freestanding location*
  • $50 copay at an outpatient hospital setting*

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

  • $0 copay in an office*
  • $15 copay at a 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*
  • $75 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $75 copay at an outpatient hospital setting

$50 copay*

$25 copay*

$15 copay*

Pharmacy (Part D) Deductible

$150 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.

$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: $0 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 30% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $10 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: $0 per prescription
  • Tier 3: $42 per prescription
  • Tier 4: $95 per prescription
  • Tier 5: 33% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: $42 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: $25 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: $105 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: $105 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*

$10 per prescription*

$0 per prescription*

$0 per prescription*

Dental

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


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

$1,000 a year for all covered dental services

  • Free preventive care
  • $6,000 per year toward comprehensive dental

  • Free preventive care
  • $7,500 per year toward comprehensive dental

Food & Home Card

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

Not covered

Not covered

$55 per month

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

Not covered

Over-the-Counter Credit

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

$100 per quarter (every 3 months)

$55 per quarter (every 3 months)

$55 per quarter (every 3 months)

$170 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.

  • $0 copay per ear for Advanced Aids*
  • $299 copay per ear for Premium Aids*

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

  • $199 copay per ear for Advanced Aids*
  • $499 copay per ear for Premium Aids*

  • $199 copay per ear for Advanced Aids*
  • $499 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

$400 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

  • $0 copay for yearly routine eye exam*
  • $500 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

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

Join CHOICE (PPO)

*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.