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Devoted CHOICE Arizona (PPO)
Devoted CHOICE GIVEBACK Arizona (PPO)

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Devoted CHOICE Arizona (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CHOICE GIVEBACK Arizona (PPO)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

You must continue to pay your part B premium.

$0

Also, your Part B premium is reduced by up to $105 per month.

Part B Giveback

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

None

Up to $105 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:

  • $5,900


In- and Out-of-network:

  • $8,950

In-network:

  • $8,300


In- and Out-of-network:

  • $10,000

Primary Care Provider (PCP) Visits

In-network:

  • $0 copay*


Out-of-network:

  • $40 copay

In-network:

  • $0 copay*


Out-of-network:

  • $50 copay

Specialist Visits

In-network:

  • $40 copay*


Out-of-network:

  • $40 copay

In-network:

  • $50 copay*


Out-of-network:

  • $50 copay

Inpatient Hospital Stays

In-network:

  • Days 1 - 7
    $335 copay per day

    Day 8+
    $0 copay per day*


Out-of-network:

  • Days 1 - 7
    $335 copay per day

    Day 8+
    $0 copay per day

In-network:

  • Days 1 - 4
    $495 copay per day

    Day 5+
    $0 copay per day*


Out-of-network:

  • Days 1 - 4
    $495 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:

  • $250 copay* at an ambulatory surgery center
  • $300 copay* at an outpatient hospital


Out-of-network:

  • $250 copay at an ambulatory surgery center
  • $300 copay at an outpatient hospital

In-network:

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


Out-of-network:

  • $350 copay at an ambulatory surgery center
  • $400 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

$100 copay per stay

Urgent Care Center Visit

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

$50 copay

$55 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*
  • $100 copay at an outpatient hospital setting*


Out-of-network:

  • $0 copay in an office or freestanding location
  • $100 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*
  • $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

In-network:

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


Out-of-network:

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

Pharmacy (Part D) Deductible

$200 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.

$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: $10 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: 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: $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: $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.

$10 per prescription*

$5 per prescription*

Dental

$1,750 yearly allowance for all covered dental services

$250 yearly allowance for all covered dental services

Food & Home Card

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

$55 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

$50 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

$200 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

$200 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.