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Devoted CORE San Antonio (HMO)
Devoted PRIME San Antonio (HMO)

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Devoted CORE San Antonio (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted PRIME San Antonio (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

You must continue to pay your part B premium.

$15

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

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.

$3,900

$3,900

Primary Care Provider (PCP) Visits

$0 copay*

$0 copay*

Specialist Visits

$15 copay*

A referral from your PCP may be required to see a specialist.

$10 copay*

A referral from your PCP may be required to see a specialist.

Inpatient Hospital Stays

Days 1 - 5
$100 copay per day

Day 6+
$0 copay per day*

Days 1 - 5
$100 copay per day

Day 6+
$0 copay per day*

Outpatient Surgery

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

  • $50 copay* at an ambulatory surgery center
  • $100 copay* at an outpatient hospital

  • $25 copay* at an ambulatory surgery center
  • $100 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

Urgent Care Center Visit

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

$20 copay

$20 copay

Labs

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

  • $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*
*

X-rays and Ultrasounds

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

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

  • $0 copay in an office or freestanding location*
  • $75 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.

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

  • $0 copay in an office or freestanding location*
  • $75 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.

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: $40 per prescription
  • Tier 4: $99 per prescription
  • Tier 5: 33% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: 25% of the total cost
  • Tier 4: 25% of the total cost
  • 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: $100 per prescription
  • Tier 4: $297 per prescription
  • Tier 5: Not available through mail

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

Dental

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

  • 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.

Over-the-Counter Credit

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

$215 per quarter (every 3 months)

$195 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*

Hearing Aids

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

  • $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

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

  • $0 copay for yearly routine eye exam*
  • $325 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*
  • $300 per year to spend on fitness trackers, home gym equipment, and more

Rides to the Doctor

Each "ride" is a 1-way trip. So going to and from your doctor uses 2 of your rides.

*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.