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Devoted CHOICE GIVEBACK Polk (PPO)
Devoted ESSENTIALS Tampa (HMO)
Devoted CORE Tampa (HMO)
Devoted PREMIUM Florida (HMO)

Want help enrolling? Give us a call.

1-800-990-0723 (TTY 711)

Devoted CHOICE GIVEBACK Polk (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted ESSENTIALS Tampa (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE Tampa (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted PREMIUM Florida (HMO)

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

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

$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.

$21.90

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.

Up to $164.90 per month

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:

  • $5,500


In- and Out-of-network:

  • $5,500

$4,900

$2,300

$3,200

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

$35 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.

$0 copay*

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

Inpatient Hospital Stays

In-network:

  • Days 1 - 5
    $295 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $295 copay per day

    Day 6+
    $0 copay per day

Days 1 - 6
$250 copay per day

Day 7+
$0 copay per day*

Days 1 - 5
$50 copay per day

Day 6+
$0 copay per day*

$0 copay per stay*

Outpatient Surgery

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

In-network:

  • $150 copay* at an ambulatory surgery center
  • $295 copay* at an outpatient hospital


Out-of-network:

  • $150 copay at an ambulatory surgery center
  • $295 copay at an outpatient hospital

  • $95 copay* at an ambulatory surgery center
  • $250 copay* at an outpatient hospital

  • $25 copay* at an ambulatory surgery center
  • $90 copay* at an outpatient hospital

  • $0 copay* at an ambulatory surgery center
  • $25 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

$120 copay per stay

Urgent Care Center Visit

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

$50 copay

$50 copay

$40 copay

$0 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 in an office or freestanding location*
    • $40 copay at an outpatient hospital setting*
    *


Out-of-network:

    • $0 copay in an office or freestanding location
    • $40 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*
  • $40 copay at an outpatient hospital setting*
*

  • $0 copay in an office or freestanding location*
  • $25 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.

In-network:

  • $0 copay in an office or freestanding location*
  • $150 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $150 copay at an outpatient hospital setting

  • $0 copay in an office or freestanding location*
  • $150 copay at an outpatient hospital setting*

  • $0 copay in an office or freestanding location*
  • $90 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*
  • $175 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $175 copay at an outpatient hospital setting

  • $0 copay in an office or freestanding location*
  • $250 copay at an outpatient hospital setting*

  • $0 copay in an office or freestanding location*
  • $90 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

$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.

$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.

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: $47 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: 30% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: $8 per prescription
  • Tier 4: $100 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: $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: $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: $20 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: 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*

$5 per prescription*

$0 per prescription*

$0 per prescription*

Dental

$1,250 yearly allowance for all covered Dental Services and/or Eyewear

  • Free preventive care
  • $1,500 per year toward comprehensive dental

  • Free preventive care
  • $3,000 per year toward comprehensive dental

  • Free preventive care
  • $2,000 per year toward comprehensive dental

Food & Home Card

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

Not covered

Not covered

$50 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

$45 per quarter (every 3 months)

$60 per quarter (every 3 months)

$140 per quarter (every 3 months)

$250 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.

  • $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*

Vision

In-network:

  • $0 copay for yearly routine eye exam*
  • Free contact lens fitting

Out-of-network:

  • $0 copay for yearly routine eye exam

Use your $1,250 Dental and Eyewear Allowance 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
  • $100 for additional eyewear costs
  • 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

Join CHOICE GIVEBACK (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.