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Devoted CHOICE Oregon (PPO)
Devoted CHOICE PLUS Oregon (PPO)
Devoted CORE Oregon (HMO)

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Devoted CHOICE Oregon (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CHOICE PLUS Oregon (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE Oregon (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

You must continue to pay your part B premium.

$12

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.

$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

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:

  • $5,900


In- and Out-of-network:

  • $8,950

In-network:

  • $5,400


In- and Out-of-network:

  • $8,950

$5,200

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $20 copay

In-network:

  • $0 copay*


Out-of-network:

  • $10 copay

$0 copay*

Specialist Visits

In-network:

  • $30 copay*


Out-of-network:

  • $30 copay

In-network:

  • $20 copay*


Out-of-network:

  • $20 copay

$20 copay*

Inpatient Hospital Stays

In-network:

  • Days 1 - 4
    $375 copay per day

    Day 5+
    $0 copay per day*


Out-of-network:

  • Days 1 - 4
    $375 copay per day

    Day 5+
    $0 copay per day

In-network:

  • Days 1 - 5
    $300 copay per day

    Day 6+
    $0 copay per day*


Out-of-network:

  • Days 1 - 5
    $300 copay per day

    Day 6+
    $0 copay per day

Days 1 - 5
$375 copay per day

Day 6+
$0 copay per day*

Outpatient Surgery

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

In-network:

  • $300 copay* at an ambulatory surgery center
  • $350 copay* at an outpatient hospital


Out-of-network:

  • $300 copay at an ambulatory surgery center
  • $350 copay at an outpatient hospital

In-network:

  • $200 copay* at an ambulatory surgery center
  • $250 copay* at an outpatient hospital


Out-of-network:

  • $200 copay at an ambulatory surgery center
  • $250 copay at an outpatient hospital

  • $300 copay* at an ambulatory surgery center
  • $350 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

Urgent Care Center Visit

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

$45 copay

$35 copay

$40 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*

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

  • $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

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*
  • $30 copay at an outpatient hospital setting*

Pharmacy (Part D) Deductible

$225 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.

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: 29% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $0 per prescription
  • Tier 3: $45 per prescription
  • Tier 4: $95 per prescription
  • Tier 5: 30% 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

  • Tier 1: $0 per prescription
  • Tier 2: $0 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: $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*

$0 per prescription*

$0 per prescription*

Dental

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


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

  • Free preventive care
  • $4,000 per year toward comprehensive dental


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

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

Food & Home Card

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

Not covered

$60 per month

The Food & Home Card is available to members with eligible chronic health conditions.

$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

$100 per quarter (every 3 months)

$50 per quarter (every 3 months)

$80 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*

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*

  • $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

$300 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*
  • $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

Naturopath Services

Office visits to a Naturopath. Covered services do not include herbs, homeopathic remedies, medications and nutritional supplements, vitamins or vitamin injections.

In-network:

  • $10 copay*


Out-of-network:
  • 20% coinsurance


Up to 12 visits per year

In-network:

  • $10 copay*


Out-of-network:
  • 20% coinsurance


Up to 12 visits per year

$10 copay*

12 visits per year

Massage Therapy

In-network:

  • $10 copay*


Out-of-network:
  • 20% coinsurance


Up to 6 visits per year

In-network:

  • $10 copay*


Out-of-network:
  • 20% coinsurance


Up to 6 visits per year

$10 copay*

6 visits per year

Routine Acupuncture

This goes beyond Medicare's benefit, which covers treatment only for chronic lower back pain.

In-network:
$0 copay*

Out-of-network:
$0 copay

Up to 12 visits per year

In-network:
$0 copay*

Out-of-network:
$0 copay

Up to 12 visits per year

$0 copay *

Up to 12 visits per year

*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.