Plans in Your Area

Viewing

Do you have a chronic health condition? View our C-SNP HMO plan

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

Want help enrolling? Give us a call.

1-800-990-0723 (TTY 711)

Devoted CHOICE Arizona (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted LIBERTY Arizona (HMO)

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

Devoted PREMIUM Arizona (HMO)

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

Monthly Premium

$0

You must continue to pay your part B premium.

$0

Also, your Part B premium is reduced by up to $125 per month.

$0

Also, your Part B premium is reduced by up to $145 per month.

$0

You must continue to pay your part B premium.

$11.40

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 $125 per month

Up to $145 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:

  • $4,900


In- and Out-of-network:

  • $8,950

$4,400

$8,300

$3,200

$3,200

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $25 copay

$0 copay*

$0 copay*

$0 copay*

$0 copay*

Specialist Visits

In-network:

  • $25 copay*


Out-of-network:

  • $25 copay

$40 copay*

$50 copay*

$15 copay*

$5 copay*

Inpatient Hospital Stays

In-network:

  • Days 1 - 7
    $250 copay per day

    Day 8+
    $0 copay per day*


Out-of-network:

  • Days 1 - 7
    $250 copay per day

    Day 8+
    $0 copay per day

Days 1 - 7
$225 copay per day

Day 8+
$0 copay per day*

Days 1 - 4
$495 copay per day

Day 5+
$0 copay per day*

Days 1 - 7
$175 copay per day

Day 8+
$0 copay per day*

Days 1 - 7
$175 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:

  • $150 copay* at an ambulatory surgery center
  • $250 copay* at an outpatient hospital


Out-of-network:

  • $150 copay at an ambulatory surgery center
  • $250 copay at an outpatient hospital

  • $100 copay* at an ambulatory surgery center
  • $200 copay* at an outpatient hospital

  • $350 copay* at an ambulatory surgery center
  • $400 copay* at an outpatient hospital

  • $75 copay* at an ambulatory surgery center
  • $175 copay* at an outpatient hospital

  • $25 copay* at an ambulatory surgery center
  • $175 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

$100 copay per stay

$135 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.

$40 copay

$50 copay

$55 copay

$15 copay

$5 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*

$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

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

  • $0 copay in an office or freestanding location*
  • $100 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*
  • $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*
  • $30 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $30 copay at an outpatient hospital setting

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

  • $0 copay in an office or freestanding location*
  • $100 copay at an outpatient hospital setting*

  • $0 copay in an office or freestanding location*
  • $50 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

$175 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.

Not covered

$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.

$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.

30-Day Supply Retail Pharmacy

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

  • Tier 1: $0 per prescription
  • Tier 2: $10 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 30% of the total cost

Not covered

  • 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

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $45 per prescription
  • Tier 4: $95 per prescription
  • Tier 5: 33% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $45 per prescription
  • Tier 4: $95 per prescription
  • Tier 5: 30% 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: $25 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: $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: $112.50 per prescription
  • Tier 4: $285 per prescription
  • Tier 5: Not available through mail

  • Tier 1: $0 per prescription
  • Tier 2: $12.50 per prescription
  • Tier 3: $112.50 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.

$10 per prescription*

Not covered

$5 per prescription*

$5 per prescription*

$5 per prescription*

Dental

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


This plan also includes out-of-network dental coverage

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

$1,000 a year for all covered dental services

  • Free preventive care
  • $7,500 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

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

$115 per quarter (every 3 months)

$50 per quarter (every 3 months)

Not covered

$145 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*

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*

  • $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

$250 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*
  • $200 toward glasses or contacts
  • Free contact lens fitting

  • $0 copay for yearly routine eye exam*
  • $300 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*
  • $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

  • Free SilverSneakers membership*
  • $150 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.

$20 copay*

12 visits per year

$20 copay*

12 visits per year

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.