SUMMARY OF BENEFITS - PDF document

1 2021 | SUMMARY OF BENEFITS Devoted Healt
2021 | SUMMARY OF BENEFITS Devoted Health Core Greater Houston (HMO) Plan PBP Number : H7993-001 b Brazoria, Fort Bend, Galveston, Harris, Montgomery, Walker, Waller Counties Need Help? Call 1-800-385-0916 (TTY 711) 1 Devoted Health Core Greater Houston (HMO) Summary of Benefits This Summary of Benefits tells you about our Devoted Health Core Greater Houston (HMO) plan. It includes information on plan costs and some of the common services we cover. It's valid for the 2021 plan year, which starts on January 1, 2021 and ends December 31, 2021. Because this document is a summary, it doesn't list all of the coverage details for this plan. If you need to know more, check the plan's Evidence of Coverage at www.devoted.com. Or, call us at 1-800-385-0916 (TTY 711) and we can mail you one. Can I join this plan? To join Devoted Health Core Greater Houston (HMO), you must be entitled to Medicare Part A and enrolled in Medicare Part B. You also ]VkZida^kZ^ci]^heaVc¸hhZgk^XZVgZV!l]^X] includes these counties: Brazoria, Fort Bend, Galveston, Harris, Montgomery, Walker, Waller. We offer different plans for other counties. Does this plan cover my prescription drugs? Find out by searching our online drug list at www.devoted.com/search-drugs . Or, give us a call. We can look up your medications or mail you our list of covered drugs (formulary). Does this plan cover my doctors a

2 nd pharmacies? Find out by searching ou
nd pharmacies? Find out by searching our online directory at www.devoted.com/search-providers . Or, give us a call. We can look up your doctors and pharmacies or mail you a directory. L]Vi¸hi]ZY^[[ZgZcXZWZilZZcXdeVnhVcY coinsurance? A copay is a flat fee. For example, a $5 copay for a service means you pay $5. Coinsurance is a percentage of the cost. For example, 10% coinsurance means you pay 10% of the cost of the service. How can I learn about Original Medicare? Check the latest Medicare & You handbook. If ndjYdc¸i]VkZdcZ!k^h^illl#bZY^XVgZ#\dk VcYZciZgµBZY^XVgZNdj]VcYWdd`¶^ci]Z search tool. (Include the quotation marks for best results.) b Or ask Medicare to send you one by calling 1-800-MEDICARE (1-800-633-4227) any day, any time. TTY users can dial 1-877-486-2048. How can I get more help? 8VaajhVi&"-%%"(-*"%.&+IIN,&&#LZ¸gZ here 8am to 8pm, Monday to Friday (from October 1 to March 31, 8am to 8pm, 7 days a week). b You can also visit us online at www.devoted.com. Devoted Health offers Medicare Advantage HMO plans with a Medicare contract. Enrollment in the Plan depends on contract renewal. 2 Devoted Health Core Greater Houston (HMO) Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fu

3 lly understand our benefits and rules.
lly understand our benefits and rules. If you have any questions, you can call Member Services at 1-800-385-0916 (TTY 711). Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.devoted.com or call 1-800-385-0916 (TTY 711) to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the Devoted Health network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescription medicine is in the Devoted Health network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules You must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. Benefits, premiums, and/or copayments/co-insurance may change on January 1, 2022. Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). Need Help? Call 1-800-385-0916 (TTY 711) 3 Monthly Premium, Deductible, and Limits Monthly Premium $0 You must continue to pay your part B premium. Medical Deductible This plan does not have a deductible. Pharmacy (Part D) Deductible This pla

4 n does not have a deductible. Maximum Ou
n does not have a deductible. Maximum Out-of-pocket Responsibility $3,400 This is the most you will pay for copays, coinsurance, and other costs for Medicare-covered medical services, supplies, and Part B-covered medication for the plan year. What you pay out-of-pocket for Part D prescription drugs and certain supplemental benefits (dental, hearing aids) do not apply to this amount. b Covered Medical and Hospital Benefits Inpatient Hospital Coverage Prior authorization may be required. $225 copay per stay b 4 Devoted Health Core Greater Houston (HMO) Outpatient Hospital Coverage Prior authorization may be required for procedures performed in Outpatient Hospital or Ambulatory Surgical Center. If you are held in Observation, you will pay your copay for the Observation Stay. Copays for any additional services provided while in Observation will not apply. Diagnostic Colonoscopies $0 copay at any in-network location Ambulatory Surgical Center (ASC) $75 copay for surgery at an ASC Outpatient Hospital $150 copay for surgery at an outpatient hospital Observation Stays $225 copay per stay Doctor Visits A referral from your PCP may be required to see a specialist. Primary Care Provider (PCP) $0 copay Specialist $15 copay Need Help? Call 1-800-385-0916 (TTY 711) 5 ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ Preventive Care Our plan covers many preventive services at no cost when you see an in-network p

5 rovider, including: Abdominal aortic ane
rovider, including: Abdominal aortic aneurysm screening b Alcohol misuse counseling b Annual wellness visit b Bone mass measurement (bone density) b Breast cancer screening (mammogram) b Cardiovascular disease (behavorial therapy) b Cardiovascular screenings b Cervical and vaginal cancer screenings b Colorectal cancer screenings (colonscopy, fecal occult blood test, flexible sigmoidoscopy, Cologuard) b Depression screening b Diabetes screening b Diabetes self-management training Glaucoma tests b Hepatitis C screening test HIV screening b Lung cancer screening b Medical nutrition therapy services b Obesity screening and counseling b Prostate cancer screenings (PSA) b Routine physical exam b Sexually transmitted infections screening and counseling b Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) b Vaccines covered under the medical benefit, including flu shots, hepatitis B shots, pneumococcal shots b µLZaXdbZidBZY^XVgZ¶egZkZci^kZk^h^idcZ time) b b Any additional preventive services approved by Medicare during the contract year will be covered. 6 Devoted Health Core Greater Houston (HMO) Emergency Care This plan also covers you for Emergency Care provided worldwide. $120 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for the emergency care. Urgently Need

6 ed Services This plan also covers you fo
ed Services This plan also covers you for Urgently Needed Services provided worldwide. Urgently needed services from your PCP: $0 copay Urgently needed services from an urgent care center: $40 copay Urgently needed services are provided to treat a non- emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Outpatient Care and Services Diagnostic Services, Labs and Imaging Prior authorization may be required. If your provider bills us as part of a hospital system, you may be responsible for the outpatient hospital setting cost share for the services outlined in this section. Lab Services $0 copay Outpatient X-rays & Ultrasounds $0 copay b in an office or free-standing location $50 copay at an outpatient hospital setting Diagnostic Radiology (such as CT, MRI, etc.) $0 copay b in an office or free-standing location $100 copay at an outpatient hospital setting Diagnostic Tests and Procedures (such as a stress test, etc.) $0 copay b in an office or free-standing location $50 copay at an outpatient hospital setting Radiation Therapy 10% coinsurance Need Help? Call 1-800-385-0916 (TTY 711) 7 ™ ™ ™ ™ Hearing Services Hearing Care Routine Hearing Exams $0 copay ´ 1 visit per year Hearing Aid Fitting and Evaluation $0 copay ´ 1 visit per year Medicare-covered Hearing Care $15 copay Hearing Aids Benefit includes coverage of up to two TruHearing Advanced or Premium hea

7 ring aids, which come in various styles
ring aids, which come in various styles and colors. b You must see a TruHearing provider to use this benefit. $399 copay per aid for Advanced Aids* $699 copay per aid for Premium Aids* You are covered for up to two advanced or premium hearing aids, which come in various styles and colors. Hearing aid purchase includes: 3 follow-up provider visits within first year of hearing aid purchase 45-day trial period 3-year extended warranty 48 batteries per aid for non-rechargeable models *Hearing aid copayments are not subject to the out- of-pocket maximum. 8 Devoted Health Core Greater Houston (HMO) Dental Services Preventive Dental Services Periodic Oral Exams $0 copay Comprehensive Oral Evaluation $0 copay Cleanings $0 copay X-rays (bitewing, intraoral, and panoramic) $0 copay Comprehensive Dental Services Devoted Health will pay as much as $1,500 per year for comprehensive dental services. b This means you will pay any additional costs above this amount. Certain limitations apply. See the plan's Evidence of Coverage (EOC) for details. Prior authorization may be required. Fillings $0 copay Root Planing & Scaling $0 copay Simple Extractions $0 copay Root Canals 50% coinsurance Crowns (Porcelain) 50% coinsurance Crowns (Resin) $0 copay Need Help? Call 1-800-385-0916 (TTY 711) 9 Medicare-covered Dental Services An example of Medicare-covered dental is the reconstruction of the jaw following accidental injury

8 . b A referral may be required. $15 co
. b A referral may be required. $15 copay Vision Services Routine Vision Routine Eye Exam $0 copay Diabetic Eye Exam $0 copay Glaucoma Screening $0 copay Eyewear Up to $200 each year for eyeglasses or contacts Fitting for contact lenses covered at no additional cost. Medicare-covered Vision Care A referral may be required $15 copay Additional Outpatient Care and Services Mental Health Services Prior authorization may be required. Inpatient mental health care $350 copay per stay b Outpatient mental health care (individual and group) $15 copay 10 Devoted Health Core Greater Houston (HMO) Skilled Nursing Facility (SNF) Prior authorization may be required. No prior hospital stay required. Days 1 - 20 $0 copay Days 21 - 40 $178 copay per day Days 41 - 100 $0 copay Physical Therapy You may need a referral for Physical, Occupational, and Speech Therapy services. $0 copay b in an office or free-standing location $40 copay at an outpatient hospital setting Ambulance Services This plans covers you for ambulance transportation to the nearest emergency room worldwide. Ground Ambulance $250 copay Air Ambulance 20% coinsurance Transportation Trips to your Primary Care Provider $0 copay ´ unlimited rides Non-emergent medical transportation $0 copay ´ 30 one-way rides per year Trips limited to 50 miles per one-way trip. Need Help? Call 1-800-385-0916 (TTY 711) 11 Prescription Drug Benefits Medicare Part B Drugs Generally, Pa

9 rt B drugs are usually not self-adminis
rt B drugs are usually not self-administered. These drugs can be given in a YdXidg¸hd[[^XZVheVgid[V medical service. In a hospital outpatient department, coverage generally is limited to drugs that are given by infusion or injection. Prior authorization may be required. Allergy Serum $0 copay Generic Medications Used in a Nebulizer $0 copay Chemotherapy Drugs 20% coinsurance Other Part B Drugs 20% coinsurance Prescription Drugs Pharmacy (Part D) Deductible This plan does not have a deductible. Initial Coverage Stage You pay copays or coinsurance until your total yearly drug costs reach $4,130. Total yearly drug costs are the total drug cost paid by both you and Devoted Health. 30-Day Supply Network Retail Pharmacy Cost sharing may change when you enter a new phase of the Part D benefit. Tier 1 : Preferred Generic $0 per prescription Tier 2 : Generic $0 per prescription Tier 3 : Preferred Brand $40 per prescription Tier 4 : Non-Preferred Drugs $80 per prescription Tier 5 : Specialty 33% of the total cost 12 Devoted Health Core Greater Houston (HMO) 100-Day Supply Network Mail Order Cost sharing may change when you enter a new phase of the Part D benefit. Tier 1 : Preferred Generic $0 per prescription Tier 2 : Generic $0 per prescription Tier 3 : Preferred Brand $100 per prescription Tier 4 : Non-Preferred Drugs $240 per prescription Tier 5 : Specialty Not avail

10 able through mail Senior Savings Model -
able through mail Senior Savings Model - Insulin Savings As a member of this plan, you have extra coverage and savings for certain insulin drugs. With this plan, you pay a $35 copay for Tier 3 insulin products covered on our formulary . b The $35 copay applies during all phases of the Part D benefit (including the coverage gap) until you reach your yearly out-of-pocket limit for b drug b costs. Erectile Dysfunction Drugs (ED) Sildenafil (generic Viagra) is covered as a Tier 2 medication. You are covered for up to 6 pills per month (a maximum of 72 pills per year). Additional Prescription Drug Information If you receive Extra Help from Medicare, your costs for prescription drugs may be lower than the cost-shares in this booklet. You pay whichever is less. Medicare beneficiaries who receive assistance from Medicaid or the state-sponsored Qualified Medicare Beneficiary program may pay nothing for Medicare- covered services. You must meet certain income and resource conditions to be eligible. If you reside in a long term care facility, you pay the same as at a standard retail pharmacy. Coverage Gap or "Donut Hole" BdhiBZY^XVgZYgj\eaVch]VkZV8dkZgV\Z temporary change in what you will pay for your drugs. The Coverage Gap begins after the total Need Help? Call 1-800-385-0916 (TTY 711) 13 yearly drug costs (including what Devoted Health has paid and what you have paid) reaches $4,1

11 30. Please note that not everyone will e
30. Please note that not everyone will enter the Coverage Gap. b For the 2021 plan year, while in the coverage gap, you will still pay $0 for drugs in tiers 1-2, and 25% of the total cost for drugs in higher tiers until you reach $6,550 total out-of-pocket. Catastrophic Coverage Yearly Out-of-pocket Drug Costs After you reach $6,550 yearly out-of-pocket drug costs, you pay the greater of: 5% of the cost ´ or ´ Generic Drugs or Drugs that are Treated as Generic $3.70 Covered Brand Drugs $9.20 Devoted Health pays the rest of the cost. Additional Benefits Dialysis A referral may be required. 20% coinsurance Foot Care (Podiatry Services) A referral may be required. Medicare-covered Foot Care $15 copay Routine Foot Care $15 copay ´ 6 visits per year Routine foot care includes hygienic care such as nail trimming and callus removal. 14 Devoted Health Core Greater Houston (HMO) ™ ™ ™ ™ ™ ™ ™ ™ ™ ™ Home Health Care Prior authorization may be required. Home Health Care is limited to Medicare-covered services. $0 copay Durable Medical Equipment (DME) Prior authorization may be required. Equipment is covered only from certain brands and manufacturers. Please contact us for details. Basic Medicare-covered DME products 20% coinsurance Advanced Medicare-covered DME products (listed below) 20% coinsurance Medicare-covered ventilator b Bone growth stimulator b Portable oxygen concentrator b Bariatric equip

12 ment b Specialty beds b Custom or spec
ment b Specialty beds b Custom or specialty wheelchairs and scooters b Seat Lifts b Specialty brand items b High-frequency chest compression vests b Pain infusion pump Need Help? Call 1-800-385-0916 (TTY 711) 15 Diabetic Monitoring Supplies Prior authorization may be required. "Fingerstick" Glucose Monitors: We cover blood glucose monitors and test strips made by LifeScan (OneTouch). Supplies provided by in-network pharmacies and DME suppliers that carry it. Continuous Glucose Monitor (CGM): Our preferred product is the Freestyle Libre and is available at in-network pharmacies at no cost to you, when ordered by your physician. Other CGMs are available but require authorization and a Durable Medical Equipment (DME) cost share may apply. Supplies to monitor your blood glucose $0 copay Rehabilitation Services You may need a referral for Physical, Occupational, and Speech Therapy services. Cardiac rehabilitation services $15 copay Pulmonary rehabilitation services $15 copay Physical Therapy $0 copay b in an office or free-standing location $40 copay at an outpatient hospital setting Occupational Therapy $0 copay b in an office or free-standing location $40 copay at an outpatient hospital setting Speech Therapy $0 copay b in an office or free-standing location $40 copay at an outpatient hospital setting Substance Use Services $15 copay 16 Devoted Health Core Greater Houston (HMO) Telehealth This benefit may not

13 be offered by all in-network plan prov
be offered by all in-network plan providers. Check directly with your provider about the availability of telehealth services. Virtual PCP Visits $0 copay Virtual PT/OT/SP Visits $15 copay Virtual Specialist Visits $15 copay Your costs may be less depending on the provider you see. More Benefits and Perks With Your Plan Over-the-counter Items (OTC) $50 per month You can use this benefit more than once, up to the limit, but this amount does not rollover. Eligible items are listed in the OTC catalog. Items not listed in the OTC catalog are not covered under the OTC benefit. Need Help? Call 1-800-385-0916 (TTY 711) 17 1. 2. 3. 4. 5. Fitness SilverSneakers: Devoted Health covers the full cost of this benefit. Devoted Health Wellness Bucks: Devoted Health will reimburse you up to $150 per year for participation or purchase of one or more of the following: Purchase of an Apple Watch® or other wearable device that tracks number of steps and heart rate. Fitness equipment to be used in the home. Examples include free weights, treadmill or stationary bike, rowing machines, resistance bands, etc. Participation in instructional fitness classes such as Yoga, Pilates, Zumba, Tai Chi, Crossfit, aerobics/group fitness classes, strength training, spin classes, personal training (taught by a certified instructor), or membership fees associated with a qualifying fitness facility. Program fees for weight loss programs such as Jenny Cr

14 aig, Weight Watchers, or hospital-based
aig, Weight Watchers, or hospital-based weight loss programs. Memory fitness activities and programs that ^begdkZndjgWgV^c¸hheZZYVcYVW^a^in! strengthen memory, and enable learning. Acupuncture Medicare coverage is limited to treatment of chronic lower back pain. Certain restrictions and limitations apply. Routine acupuncture can be used for the treatment of any condition. Medicare-covered acupuncture $0 copay b Routine acupuncture $0 copay ´ 12 visits per year 18 Devoted Health Core Greater Houston (HMO) ™ ™ ™ Meals After an Inpatient or Skilled Nursing Facility Stay $0 copay After an inpatient stay in a hospital or a skilled nursing facility, you can get 2 meals per day for up to 10 days at no extra cost to you. This benefit may be used up to 4 times per calendar year. After a New Chronic Condition $0 copay If part of your care plan for a chronic condition means changing how you eat, you can have meals delivered to your home to help you get started. b You can get 2 meals a day for 14 days. You can use this service once per calendar year, per new diagnosis. Chiropractic Care Medicare-covered chiropractic services $15 copay Bathroom Safety Equipment Standard Raised Toilet Seat: $0 copay Standard Tub Seat: $0 copay Personal Emergency Response Device (PERS) A Personal Emergency Response System (PERS) is a medical alert monitoring system that provides 24/7 access to help at t

15 he push of a button. b We offer multip
he push of a button. b We offer multiple styles, including in-home and GPS- enabled wearable devices. $0 copay There is no cost to you to access this benefit. This includes: Cost of the device Monthly monitoring fees Fall detection (available on certain styles) Need Help? Call 1-800-385-0916 (TTY 711) 19 ™ ™ ™ Wigs for Hair Loss Related to Chemotherapy Devoted Health will reimburse you up to $500 each plan year for the purchase of wigs for hair loss related to chemotherapy. Devoted Dollars With our rewards program, you can earn Devoted Health Plans Visa® prepaid cards for taking care of yourself. When we receive a claim from your provider for any of the eligible services, we will issue you a reward. No paperwork or forms required. Annual Wellness Visit: Earn a $25 reward after an annual wellness visit or annual exam Breast Cancer Screening: Earn a $25 reward V[iZgVWgZVhiXVcXZghXgZZc^c\^[ndj¸gZYjZ[dg one) Colorectal Cancer Screening: Earn a $25 reward V[iZgVXdadgZXiVaXVcXZghXgZZc^c\^[ndj¸gZYjZ for one) Diabetes Screening : Earn a $25 reward after receiving all of the following services (if you have diabetes): Get a blood test to check you HbA1c (average blood sugar) Get a urine test to check your kidney function Get an eye exam for diabetes Flu Shot: Earn a $20 reward after receiving the flu sh

16 ot PCP Visit: Earn a $10 reward after s
ot PCP Visit: Earn a $10 reward after seeing your PCP within 90 days of your plan start date You need a referral to receive covered services from providers. b Certain procedures, services, and Ygj\hbVncZZYVYkVcXZVeegdkVa[gdb9ZkdiZY=ZVai]#I]^h^hXVaaZYµeg^dgVji]dg^oVi^dc¶dg µegZ"Vji]dg^oVi^dc#¶EaZVhZXdciVXindjgE8EdggZ[Zgidi]Z:k^YZcXZd[8dkZgV\Z[dghZgk^XZh that require a prior authorization from Devoted Health. 22 Devoted Health Core Greater Houston (HMO) This information is not a complete description of benefits. Call 1-800-385-0916 (TTY 711) for more information. Devoted Health is a HMO plan with a Medicare contract. Enrollment in Devoted Health depends on contract renewal. SilverSneakers and SilverSneakers FLEX are registered trademarks of Tivity Health, Inc. © 2019 Tivity Health, Inc. All rights reserved. H7993_21S39_M Need Help? Call 1-800-385-0916 (TTY 711) 23 24 Devoted Health Core Greater Houston (HMO) Questions? Call us. 1-800-385-0916 TTY 711 If you're a Devoted Health member, call: 1-800-338-6833 TTY 711 Questions? Call us.1-800-385-0916TTY 711If you're a Devoted Health member, call:1-800-338-6833TTY 711 ��24Devoted Health Core Greater Houston (HMO) ��Need Help? Call 1-800-385-0916

17 (TTY 711)23 ��22Devoted He
(TTY 711)23 ��22Devoted Health Core Greater Houston (HMO) ��Need Help? Call 1-800-385-0916 (TTY 711)19 Wigs for Hair Loss Related to ChemotherapyDevoted Health will reimburse you up to $500 loss related to chemotherapy.Devoted DollarsWith our rewards program, you can earn Devoted Health Plans Visa® prepaid cards for taking When we receive a claim from your provider for any of the eligible services, we will issue you a reward. No paperwork or Annual Wellness Visit: Earn a $25 reward after an annual wellness visit or annual examBreast Cancer Screening: Earn a $25 reward Colorectal Cancer Screening: Earn a $25 reward Diabetes Screening: Earn a $25 reward after receiving all of the following services (if you have Get a blood test to check you HbA1c (average blood sugar)Get a urine test to check your kidney Get an eye exam for diabetesFlu Shot: Earn a $20 reward after receiving the flu shotPCP Visit: Earn a $10 reward after seeing your PCP within 90 days of your plan start dateYou need a referral to receive covered services from providers.Certain procedures, services, and ��18Devoted Health Core Greater Houston (HMO) MealsAfter an Inpatient or Skilled Nursing Facility Stay$0 copayAfter an inpatient stay in a hospital or a skilled nursing facility, you can get 2 meals per day for up to 10 days at no extra cost to you.This benefit may be used up to 4 times per calendar year.After a New Chronic Condition$0 c

18 opayIf part of your care plan for a chro
opayIf part of your care plan for a chronic condition means changing how you eat, you can have meals delivered You can get 2 meals a day for 14 days. You can use this service once per calendar year, per new diagnosis.Chiropractic CareMedicare-covered chiropractic services$15 copayBathroom Safety EquipmentStandard Raised Toilet Seat:Standard Tub Seat:$0 copayPersonal Emergency Response Device (PERS)A Personal Emergency Response System (PERS) is a medical alert monitoring system that provides We offer multiple styles, including in-home and GPS- enabled wearable devices.$0 copayThere is no cost to you to access this benefit. This includes:Cost of the device ��Need Help? Call 1-800-385-0916 (TTY 711)17 FitnessSilverSneakers: Devoted Health covers the full cost of this benefit.Devoted Health Wellness Bucks: Devoted Health will reimburse you up to $150 per year for participation or purchase of one or more of the following:Purchase of an Apple Watch® or other wearable device that tracks number of steps and heart rate.Fitness equipment to be used in the home. Examples include free weights, treadmill or stationary bike, rowing machines, resistance bands, etc.Participation in instructional fitness classes such as Yoga, Pilates, Zumba, Tai Chi, Crossfit, aerobics/group fitness classes, strength training, spin classes, personal training (taught by a certified instructor), or qualifying fitness facility.Program fees for weight loss programs

19 such as Jenny Craig, Weight Watchers, or
such as Jenny Craig, Weight Watchers, or Memory fitness activities and programs that strengthen memory, and enable learning.AcupunctureMedicare coverage is limited to treatment of chronic lower back pain. Certain restrictions and limitations apply.Routine acupuncture can be used for the treatment of any Medicare-covered acupuncture$0 copayRoutine acupuncture$0 copay12 visits per year ��16Devoted Health Core Greater Houston (HMO) TelehealthThis benefit may not be offered by all in-network plan providers. Check directly with your provider about the availability of Virtual PCP Visits$0 copayVirtual PT/OT/SP Visits$15 copayVirtual Specialist Visits$15 copayYour costs may be less depending on the provider you see.More Benefits and Perks With Your PlanOver-the-counter Items (OTC)$50 per monthYou can use this benefit more than once, up to the limit, but this amount does not rollover.Eligible items are listed in the OTC catalog. Items not listed in the OTC catalog are not covered under the OTC benefit. ��Need Help? Call 1-800-385-0916 (TTY 711)15 Diabetic Monitoring SuppliesPrior authorization may be required."Fingerstick" Glucose Monitors: We cover blood glucose monitors and test strips made by LifeScan (OneTouch). Supplies provided by in-network pharmacies and Continuous Glucose Monitor (CGM): Our preferred product is the Freestyle Libre and is available at available but require authorization and a Durable Supplies to mon

20 itor your blood glucose$0 copayRehabilit
itor your blood glucose$0 copayRehabilitation ServicesYou may need a referral for Physical, Occupational, and Cardiac rehabilitation services$15 copayPulmonary rehabilitation services$15 copayPhysical Therapy$0 copayin an office or free-standing location$40 copay at an outpatient hospital settingOccupational Therapy$0 copayin an office or free-standing location$40 copay at an outpatient hospital settingSpeech Therapy$0 copayin an office or free-standing location$40 copay at an outpatient hospital settingSubstance Use Services$15 copay ��14Devoted Health Core Greater Houston (HMO) Home Health CarePrior authorization may be required. $0 copayDurable Medical Equipment (DME)Prior authorization may be required.certain brands and manufacturers. Please contact us Basic Medicare-covered DME products20% coinsuranceAdvanced Medicare-covered DME products (listed below)20% coinsuranceMedicare-covered ventilatorBone growth stimulatorBariatric equipmentSpecialty bedsCustom or specialty wheelchairs and scootersHigh-frequency chest compression vestsPain infusion pump ��Need Help? Call 1-800-385-0916 (TTY 711)13 yearly drug costs (including what Devoted Health has paid and what you have paid) reaches $4,130. Please note that not everyone will enter the Coverage Gap.For the 2021 plan year, while in the coverage gap, you will still pay $0 for drugs in tiers 1-2, and 25% of the total cost for drugs in higher tiers until you reach $6,5

21 50 total out-of-pocket.Catastrophic Cove
50 total out-of-pocket.Catastrophic CoverageYearly Out-of-pocket Drug CostsAfter you reach $6,550 yearly out-of-pocket drug costs, you pay the greater of:5% of the costorGeneric Drugs or Drugs that are Treated as Generic$3.70Covered Brand Drugs$9.20 Devoted Health pays the rest of the cost.Additional BenefitsDialysisA referral may be required.20% coinsuranceFoot Care (Podiatry Services)A referral may be required.Medicare-covered Foot Care$15 copayRoutine Foot Care$15 copay6 visits per year Routine foot care includes hygienic care such as nail trimming and callus removal. ��12Devoted Health Core Greater Houston (HMO) 100-Day Supply Network Mail OrderCost sharing may change when you enter a new phase of the Part D benefit.Tier 1$0 per prescriptionTier 2$0 per prescriptionTier 3: $100 per prescription: $240 per prescriptionNot available through mailSenior Savings Model - Insulin SavingsAs a member of this plan, you have extra coverage and savings for certain insulin drugs.With this plan, you pay a $35 copay forinsulin.The $35 copay applies during all phases of the Part D benefit (including the coverage gap) until you reach your yearly out-of-pocket limit fordrugcosts.Erectile Dysfunction Drugs (ED)Sildenafil (generic Viagra) is covered as a Tier 2 month (a maximum of 72 pills per year).Additional Prescription Drug If you receive Extra Help from Medicare, your costs for prescription drugs may be lower than the cost-shares Medicare be

22 neficiaries who receive assistance from
neficiaries who receive assistance from Medicaid or the state-sponsored Qualified Medicare Beneficiary program may pay nothing for Medicare- covered services. You must meet certain income and If you reside in a long term care facility, you pay the same as at a standard retail pharmacy.Coverage Gap or "Donut Hole"temporary change in what you will pay for your drugs. The Coverage Gap begins after the total ��Need Help? Call 1-800-385-0916 (TTY 711)11 Prescription Drug BenefitsMedicare Part B DrugsGenerally, Part B drugs are usually not self-administered. These drugs can be given in a medical service. In a hospital outpatient department, coverage are given by infusion or injection.Prior authorization may be required.Allergy Serum$0 copayGeneric Medications Used in a Nebulizer$0 copayChemotherapy Drugs20% coinsuranceOther Part B Drugs20% coinsurance Prescription DrugsPharmacy (Part D) Deductible This plan does not have a deductible. Initial Coverage Stage You pay copays or coinsurance until your total yearly drug costs reach $4,130. Total yearly drug costs are the total drug cost paid by both you and Devoted Health.30-Day Supply Network Retail PharmacyCost sharing may change when you enter a new phase of the Part D benefit.Tier 1$0 per prescriptionTier 2$0 per prescriptionTier 3: $40 per prescriptionTier 4: $80 per prescriptionTier 533% of the total cost ��10Devoted Health Core Greater Houston (HMO) Skilled Nursing Fa

23 cility (SNF)Prior authorization may be r
cility (SNF)Prior authorization may be required.No prior hospital stay required.Days 1 - 20$0 copayDays 21 - 40$178 copay per dayDays 41 - 100$0 copayPhysical TherapyYou may need a referral for Physical, Occupational, and Speech Therapy services.$0 copayin an office or free-standing location$40 copay at an outpatient hospital settingAmbulance ServicesThis plans covers you for ambulance transportation to the nearest emergency room worldwide.Ground Ambulance$250 copayAir Ambulance20% coinsuranceTransportationTrips to your Primary Care Providerunlimited ridesNon-emergent medical transportation$0 copay30 one-way rides per year Trips limited to 50 miles per one-way trip. ��Need Help? Call 1-800-385-0916 (TTY 711)9 Medicare-covered Dental ServicesAn example of Medicare-covered dental is the reconstruction of the jaw following accidental A referral may be $15 copayVision ServicesRoutine VisionRoutine Eye Exam$0 copayDiabetic Eye Exam$0 copayGlaucoma Screening$0 copayEyewearUp to $200 each year for eyeglasses or contacts Fitting for contact lenses covered at no additional Medicare-covered Vision CareA referral may be required$15 copayAdditional Outpatient Care and ServicesMental Health ServicesPrior authorization may be required.Inpatient mental health care$350 copay per stayOutpatient mental health care (individual and group)$15 copay ��8Devoted Health Core Greater Houston (HMO) Dental ServicesPreventive Dental ServicesPer

24 iodic Oral Exams$0 copayComprehensive Or
iodic Oral Exams$0 copayComprehensive Oral Evaluation$0 copayCleanings $0 copayX-rays (bitewing, intraoral, and panoramic)$0 copayComprehensive Dental Devoted Health will pay as much as $1,500 per year for services.This means you will pay any additional costs above this Certain limitations apply. See the plan's Evidence of Coverage (EOC) for details.Prior authorization may be required.Fillings$0 copayRoot Planing & Scaling $0 copaySimple Extractions $0 copayRoot Canals50% coinsuranceCrowns (Porcelain)50% coinsuranceCrowns (Resin)$0 copay ��Need Help? Call 1-800-385-0916 (TTY 711)7 Hearing ServicesHearing CareRoutine Hearing Exams$0 copay1 visit per yearHearing Aid Fitting and Evaluation$0 copay1 visit per yearMedicare-covered Hearing Care$15 copayHearing AidsBenefit includes coverage of up to two TruHearing Advanced or You must see a TruHearing provider to use this benefit.$399 copay per aid for Advanced Aids* $699 copay per aid for Premium Aids* You are covered for up to two advanced or premium hearing aids, which come in various styles and colors.Hearing aid purchase includes:3 follow-up provider visits within first year of hearing aid purchase45-day trial period*Hearing aid copayments are not subject to the out- ��6Devoted Health Core Greater Houston (HMO) Emergency CareThis plan also covers you for Emergency Care provided worldwide.$120 copay If you are admitted to the hospital within 24 hours, you do not have

25 to pay your share of the cost for the em
to pay your share of the cost for the emergency care.Urgently Needed ServicesThis plan also covers you for Urgently Needed Services provided worldwide.Urgently needed services from your PCP:$0 copayUrgently needed services from an urgent care center:$40 copay Urgently needed services are provided to treat a non- condition that requires immediate medical care.Outpatient Care and ServicesDiagnostic Services, Labs and ImagingPrior authorization may be required. If your provider bills us as part of a hospital system, you may be responsible for the outpatient the services outlined in this section.Lab Services$0 copayOutpatient X-rays & Ultrasounds$0 copayin an office or free-standing location$50 copay at an outpatient hospital settingDiagnostic Radiology (such as CT, MRI, etc.)$0 copayin an office or free-standing location$100 copay at an outpatient hospital settingDiagnostic Tests and Procedures (such as a stress test, etc.)$0 copayin an office or free-standing location$50 copay at an outpatient hospital settingRadiation Therapy10% coinsurance ��Need Help? Call 1-800-385-0916 (TTY 711)5 ��4Devoted Health Core Greater Houston (HMO) Outpatient Hospital CoveragePrior authorization may be required for procedures performed in Outpatient Hospital If you are held in Observation, you will pay your copay for the Observation Stay. Copays for any while in Observation will not apply.Diagnostic Colonoscopies$0 copay at any in-netwo

26 rk locationAmbulatory Surgical Center (A
rk locationAmbulatory Surgical Center (ASC)$75 copay for surgery at an ASCOutpatient Hospital$150 copay for surgery at an outpatient hospitalObservation Stays$225 copay per stayDoctor VisitsA referral from your PCP may be required to see a specialist.Primary Care Provider (PCP)$0 copaySpecialist$15 copay ��Need Help? Call 1-800-385-0916 (TTY 711)3 Monthly Premium, Deductible, and LimitsMonthly Premium$0You must continue to pay your part B premium.Medical DeductibleThis plan does not have a deductible.Pharmacy (Part D) DeductibleThis plan does not have a deductible.Maximum Out-of-pocket Responsibility$3,400This is the most you will pay for copays, coinsurance, and other costs for Medicare-covered medical services, supplies, and Part B-covered medication for the plan year. What you pay out-of-pocket for Part D prescription drugs and certain supplemental benefits Covered Medical and Hospital BenefitsInpatient Hospital CoveragePrior authorization may be required.$225 copay per stay ��2Devoted Health Core Greater Houston (HMO) Pre-Enrollment ChecklistBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call Member Services at 1-800-385-0916 (TTY 711).Understanding the BenefitsReview the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.devoted.com

27 or call 1-800-385-0916 (TTY 711) to vie
or call 1-800-385-0916 (TTY 711) to view a copy of Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the Devoted Health network. If they are not listed, it means you will likely Review the pharmacy directory to make sure the pharmacy you use for any prescription medicine is in the Devoted Health network. If the pharmacy is not pharmacy for your prescriptions.Understanding Important RulesYou must continue to pay your premium is normally taken out of your Social Security check each month.Benefits, premiums, and/or copayments/co-insurance may change on January 1, 2022.Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who ��Need Help? Call 1-800-385-0916 (TTY 711)1 Devoted Health Core Greater Houston (HMO)Summary of Benefits This Summary of Benefits tells you about our Devoted Health Core Greater Houston (HMO) plan. It includes information on plan costs and some of the common services we cover. It's valid for the 2021 plan year, which starts on January 1, 2021 and ends December 31, 2021. Because this document is a summary, it doesn't list all of the coverage details for this plan. If you need to know more, check the Evidence of Coverage at www.devoted.com. Or, call us at 1-800-385-0916 (TTY 711) and we can mail you one. Can I join this plan? To join Devoted Health Core Greater Houston (HMO), you must be entitled to Medicare Part A a

28 nd enrolled in Medicare Part B. You also
nd enrolled in Medicare Part B. You also includes these counties: Brazoria, Fort Bend, Galveston, Harris, Montgomery, Walker, counties. Does this plan cover my prescription drugs? Find out by searching our online drug list at www.devoted.com/search-drugs . Or, give us a call. We can look up your medications or mail you our list of covered drugs (formulary). Does this plan cover my doctors and pharmacies? Find out by searching our online directory at www.devoted.com/search-providers . Or, give us a call. We can look up your doctors and pharmacies or mail you a directory. coinsurance? A copay is a flat fee. For example, a $5 copay for a service means you pay $5. Coinsurance is a percentage of the cost. For example, 10% coinsurance means you pay 10% of the cost of How can I learn about Original Medicare? Check the latest Medicare & You handbook. If search tool. (Include the quotation marks for best results.)Or ask Medicare to send you one by calling 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048. How can I get more help? here 8am to 8pm, Monday to Friday (from October 1 to March 31, 8am to 8pm, 7 days a week). You can also visit us online at www.devoted.com. Devoted Health offers Medicare Advantage HMO plans with a Medicare contract. Enrollment in the Plan depends on contract renewal. 2021 SUMMARY OF BENEFITS Devoted Health Core Greater Houston (HMO) Plan PBP Number: H7993-001 Brazoria, Fort Bend, Galveston, Harris, Montgomery, Walker, Walle