Devoted GIVEBACK Greater Houston (HMO) H7993-006 2024 Plan Details and Costs (2024)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Referral Required for Doctor Specialty Visit

In-Network:

Acute Hospital Services:
$325.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required

Copayment for Urgent Care $0.00 to $40.00

$0 urgently needed services in PCP office.$40 urgently needed services at urgent care center.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00
Maximum Plan Benefit of $25,000

Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $250.00
Maximum Plan Benefit of $25,000

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $50.00
Copayment for Medicare-covered Lab Services $0.00 to $25.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $300.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $50.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required

In-Network:

Psychiatric Hospital Services:
$325.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $325.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $325.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $175.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required

In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $55.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

• Maximum 2 visits (Please see Evidence of Coverage for details)

Copayment for Prophylaxis (Cleaning) $0.00

• Maximum 2 visits (Please see Evidence of Coverage for details)

Copayment for Fluoride Treatment $0.00

• Maximum 2 visits (Please see Evidence of Coverage for details)

Copayment for Dental X-Rays $0.00

• Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $1000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00
Copayment for Diagnostic Services $0.00

• Maximum 2 visits (Please see Evidence of Coverage for details)

Copayment for Restorative Services $0.00

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0.00

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Extractions $0.00

• Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $1000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental
Prior authorization required

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Eye Exams $0.00

• Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Hearing Exams $0.00

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $399.00 to $699.00

• Maximum 2 Hearing Aids every year

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

• COVID-19 shots

Tobacco use cessation
Yearly "Wellness" visit