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Devoted CHOICE Illinois (PPO)
Devoted GIVEBACK Illinois (HMO)
Devoted CORE Illinois (HMO)

Want help enrolling? Give us a call.

1-800-990-0723 (TTY 711)

Devoted CHOICE Illinois (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted GIVEBACK Illinois (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE Illinois (HMO)

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

Monthly Premium

$0

You must continue to pay your part B premium.

$0

Also, your Part B premium is reduced by up to $115 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 $115 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:

  • $3,200


In- and Out-of-network:

  • $5,450

$4,500

$2,500

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $10 copay

$0 copay*

$0 copay*

Specialist Visits

In-network:

  • $20 copay*


Out-of-network:

  • $25 copay

$40 copay*

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

$15 copay*

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

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

Days 1 - 5
$395 copay per day

Day 6+
$0 copay per day*

Days 1 - 7
$150 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:

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


Out-of-network:

  • $250 copay at an ambulatory surgery center
  • $295 copay at an outpatient hospital

  • $150 copay* at an ambulatory surgery center
  • $395 copay* at an outpatient hospital

  • $95 copay* at an ambulatory surgery center
  • $150 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

$90 copay per stay

Urgent Care Center Visit

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

$45 copay

$50 copay

$25 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*
    • $10 copay at an outpatient hospital setting*
    *


Out-of-network:

    • $0 copay in an office or freestanding location
    • $25 copay at an outpatient hospital setting

$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
  • $40 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*
  • $25 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*
  • $75 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $95 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*
  • $25 copay at an outpatient hospital setting*

Pharmacy (Part D) Deductible

This plan does not have a deductible.

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: $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: $10 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: $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: $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: $25 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: $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*

$10 per prescription*

$0 per prescription*

Dental

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


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

$1,000 a year for all covered dental services

  • 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

$65 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

$155 per quarter (every 3 months)

Not covered

$65 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*

  • $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

$300 per year toward glasses or contacts

  • $0 copay for yearly routine eye exam*
  • $125 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

Rides to the Doctor

Each "ride" is a 1-way trip. So going to and from your doctor uses 2 of your rides.

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.