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Devoted CHOICE Hawaii (PPO)
Devoted CHOICE PLUS Hawaii (PPO)
Devoted CHOICE GIVEBACK Hawaii (PPO)

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Devoted CHOICE Hawaii (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CHOICE PLUS Hawaii (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CHOICE GIVEBACK Hawaii (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

You must continue to pay your part B premium.

$5.80

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.

$0

Also, your Part B premium is reduced by up to $105 per month.

Part B Giveback

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

None

None

Up to $105 per month

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:

  • $6,700


In- and Out-of-network:

  • $10,000

In-network:

  • $5,500


In- and Out-of-network:

  • $8,950

In-network:

  • $8,300


In- and Out-of-network:

  • $10,000

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

Specialist Visits

In-network:

  • $35 copay*


Out-of-network:

  • $35 copay

In-network:

  • $35 copay*


Out-of-network:

  • $35 copay

In-network:

  • $50 copay*


Out-of-network:

  • $50 copay

Inpatient Hospital Stays

In-network:

  • Days 1 - 5
    $375 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $375 copay per day

    Day 6+
    $0 copay per day

In-network:

  • Days 1 - 5
    $325 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $325 copay per day

    Day 6+
    $0 copay per day

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

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

In-network:

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


Out-of-network:

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

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

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

$100 copay per stay

Urgent Care Center Visit

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

$50 copay

$35 copay

$55 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*


Out-of-network:

  • $0 copay

In-network:

  • $0 copay*


Out-of-network:

  • $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*

Out-of-network:

$0 copay

In-network:

$0 copay*

Out-of-network:

$0 copay

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

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*


Out-of-network:


  • $0 copay

In-network:


  • $0 copay*


Out-of-network:


  • $0 copay

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

Pharmacy (Part D) Deductible

$200 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.

$200 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.

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: $45 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 30% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: $45 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 30% 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: 25% 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: $112.50 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: $112.50 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

Erectile Dysfunction Drugs

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

$0 per prescription*

$0 per prescription*

$5 per prescription*

Dental

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


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

  • Free preventive care
  • $6,000 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.

Food & Home Card

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

Not covered

$30 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

$95 per quarter (every 3 months)

$85 per quarter (every 3 months)

Not covered

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

$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

$400 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

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

Naturopath Services

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

In-network:

  • $20 copay*


Out-of-network:
  • $20 copay


Up to 12 visits per year

In-network:

  • $20 copay*


Out-of-network:
  • $20 copay


Up to 24 visits per year

Not Covered

Massage Therapy

In-network:

  • $20 copay*


Out-of-network:
  • $20 copay


Up to 6 visits per year

In-network:

  • $20 copay*


Out-of-network:
  • $20 copay


Up to 12 visits per year

Not Covered

Routine Acupuncture

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

In-network:

  • $20 copay*

Out-of-network:
  • $20 copay


Up to 24 visits per year

In-network:

  • $20 copay*

Out-of-network:
  • $20 copay


Up to 24 visits per year

Not Covered

*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.