DEVOTED CHOICE 005 NC (PPO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Devoted Health
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $5 copay
Out-of-network: $30 copay
Out-of-network: $0 copay
Emergency Room
$130 copay
Ambulance Coverage
In-network: $0-$325 copay
Out-of-network: $0-$325 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$95 copay
Out-of-network: $0-$95 copay
Lab services:
In-network: $0-$20 copay
Out-of-network: $0-$20 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$300 copay
Out-of-network: $0-$300 copay
Outpatient x-rays:
In-network: $0-$75 copay
Out-of-network: $0-$75 copay
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$395 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
$395 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Outpatient hospital coverage:
In-network: $0-$495 copay
Out-of-network: $0-$495 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $30-$50 copay
Out-of-network: $30-$50 copay
Urgent Care Coverage
$130 copay
Skilled Nursing Facility (SNF)
In-network:
Tier 1
$0 per day for days 1-20
$218 per day for days 21-100
Out-of-network:
25% per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $30 copay
Out-of-network: $30 copay
Outpatient individual therapy with a psychiatrist:
In-network: $30 copay
Out-of-network: $30 copay
Outpatient group therapy visits:
In-network: $30 copay
Out-of-network: $30 copay
Outpatient individual therapy visit:
In-network: $30 copay
Out-of-network: $30 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Fitting/evaluation:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
In-network: $399-$699 copay
Out-of-network: $399-$699 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
19% coinsurance (30-day supply)
19% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
28% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
19% coinsurance (30-day supply)
19% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
28% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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