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Devoted CHOICE Northwest Florida (PPO)
Devoted CHOICE GIVEBACK Northwest Florida (PPO)

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Devoted CHOICE Northwest Florida (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CHOICE GIVEBACK Northwest Florida (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

2024 CMS Plan Rating

Every year, Medicare evaluates plans based on a 5-star rating system.

CMS Rating not applicable

CMS Rating not applicable

Monthly Premium

$0

You must continue to pay your part B premium.

$0

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

Part B Giveback

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

None

Up to $145 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:

  • $4,900


In- and Out-of-network:

  • $8,950

In-network:

  • $6,200


In- and Out-of-network:

  • $8,950

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

In-network:

  • $0 copay*


Out-of-network:

  • $0 copay

Specialist Visits

In-network:

  • $30 copay*


Out-of-network:

  • $30 copay

In-network:

  • $40 copay*


Out-of-network:

  • $40 copay

Inpatient Hospital Stays

In-network:

  • Days 1 - 5
    $265 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $265 copay per day

    Day 6+
    $0 copay per day

In-network:

  • Days 1 - 4
    $450 copay per day

    Day 5+
    $0 copay per day*


Out-of-network:

  • Days 1 - 4
    $450 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:

  • $175 copay* at an ambulatory surgery center
  • $225 copay* at an outpatient hospital


Out-of-network:

  • $175 copay at an ambulatory surgery center
  • $225 copay at an outpatient hospital

In-network:

  • $175 copay* at an ambulatory surgery center
  • $225 copay* at an outpatient hospital


Out-of-network:

  • $175 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

Urgent Care Center Visit

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

$40 copay

$50 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

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

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

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*
  • $20 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $20 copay at an outpatient hospital setting

In-network:

  • $0 copay in an office or freestanding location*
  • $20 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $20 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: $5 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 33% 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: $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: $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.

$5 per prescription*

$5 per prescription*

Dental

  • Free preventive care
  • $3,000 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

$75 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

$80 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*

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*

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

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

*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.