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Devoted CHOICE Arizona (PPO)
Devoted LIBERTY CHOICE Arizona (PPO)
Devoted GIVEBACK Arizona (HMO)
Devoted CORE Arizona (HMO)

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Devoted CHOICE Arizona (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted LIBERTY CHOICE Arizona (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted GIVEBACK Arizona (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE Arizona (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

You must continue to pay your part B premium.

$0

Your Part B premium is reduced by up to $150.00 per month.

$0

Also, your Part B premium is reduced by up to $140 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 $150 per month

Up to $140 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:

  • $5,000


In- and Out-of-network:

  • $8,950

In-network:

  • $6,350


In- and Out-of-network:

  • $8,950

$3,900

$2,400

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $25 copay

In-network:

  • $0 copay*


Out-of-network:

  • $45 copay

$0 copay*

$0 copay*

Specialist Visits

In-network:

  • $25 copay*


Out-of-network:

  • $25 copay

In-network:

  • $45 copay*


Out-of-network:

  • $45 copay

$35 copay*

$20 copay*

Inpatient Hospital Stays

In-network:

  • Days 1 - 6
    $295 copay per day

    Day 7+
    $0 copay per day*


Out-of-network:

  • Days 1 - 6
    $295 copay per day

    Day 7+
    $0 copay per day

In-network:

  • Days 1 - 6
    $395 copay per day

    Day 7+
    $0 copay per day*


Out-of-network:

  • Days 1 - 6
    $395 copay per day

    Day 7+
    $0 copay per day

Days 1 - 6
$375 copay per day

Day 7+
$0 copay per day*

Days 1 - 7
$225 copay per day

Day 8+
$0 copay per day*

Outpatient Surgery

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

In-network:

  • $195 copay* at an ambulatory surgery center
  • $225 copay* at an outpatient hospital


Out-of-network:

  • $195 copay at an ambulatory surgery center
  • $225 copay at an outpatient hospital

In-network:

  • $295 copay* at an ambulatory surgery center
  • $350 copay* at an outpatient hospital


Out-of-network:

  • $295 copay at an ambulatory surgery center
  • $350 copay at an outpatient hospital

  • $295 copay* at an ambulatory surgery center
  • $325 copay* at an outpatient hospital

  • $125 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.

$120 copay per stay

$120 copay per stay

$120 copay per stay

$135 copay per stay

Urgent Care Center Visit

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

$35 copay

$50 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*


Out-of-network:

  • $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*
  • $10 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $10 copay at an outpatient hospital setting

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

  • $0 copay in an office or freestanding location*
  • $10 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*
  • $10 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $10 copay at an outpatient hospital setting

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

  • $0 copay in an office or freestanding location*
  • $10 copay at an outpatient hospital setting*

Pharmacy (Part D) Deductible

This plan does not have a deductible.

Not covered

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: 33% of the total cost

Not covered

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $42 per prescription
  • Tier 4: $90 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: $0 per prescription
  • Tier 3: $117.50 per prescription
  • Tier 4: $300 per prescription
  • Tier 5: Not available through mail

Not covered

  • Tier 1: $0 per prescription
  • Tier 2: $12.50 per prescription
  • Tier 3: $105 per prescription
  • Tier 4: $270 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.

$0 per prescription*

Not covered

$5 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

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

$1,000 a year for all covered dental services

  • 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

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

$125 per quarter (every 3 months)

Not covered

$50 per quarter (every 3 months)

$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.

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

  • $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

$350 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

$350 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*
  • $350 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

*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.