Devoted PREMIUM Ohio (HMO) H2697-002-000 2025 Plan Details and Costs (2025)

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35

• $300 per day from day 1
• $0 per day from day 7
• PA may be required

$0 copay for urgently needed services received by a PCP.$45 copay for urgently needed services received from an urgent care center.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $125

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Copayment for Worldwide Emergency Transportation $300

$300
PA may be required

Air or Water Ambulance

20%
PA may be required

Facility to Facility Transfer

Member will not be responsible for additional ground ambulance copays for facility to facility transfers.

Chiropractic Services - Routine Visits Copayment
Not covered

Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts
$0
PA may be required

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 50%
Prior Authorization Required for Durable Medical Equipment
Plan covers crutches with 20% coinsurance.The following DME has 50% coinsurance:Medicare-covered ventilator, Bone growth stimulator, Portable oxygen concentrator, Bariatric equipment, Specialty beds, Custom or specialty wheelchairs and scooters, Seat lifts, Specialty brand items, High Frequency Chest Compression Vests, Pain Infusion Pump, Continuous Glucose Monitor (other than Plan's preferred CGM), and Home Infusion Therapy (HIT) drugs.$0 copay for the Plan's preferred Continuous Glucose Monitor.20% coinsurance for all other DME.

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $100
Copayment for Medicare-covered Lab Services $0 to $20
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Copayment varies based on site of service:PCPs office: $0 copay for EKGs/EEGs/ECGs, $0 copay all other. Specialist office: $0 copay for EKGs/EEGs/ECGs, $45 copay all other. Freestanding facility: $45 copay for EKGs/EEGs/ECGs, $45 copay all other. Outpatient hospital: $100 copay for EKGs/EEGs/ECGs, $100 copay all other.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $200
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $100

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services

Psychiatric Hospital Services:
$300 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $400
Prior Authorization Required for Outpatient Hospital Services
$0 copay for diagnostic colonoscopies, $400 copay for all other outpatient hospital services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $300
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $300
Prior Authorization Required for Ambulatory Surgical Center Services
$0 copay for diagnostic colonoscopies, $300 copay for all other ASC services.

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Copayment for Medicare Covered Dental Services:
$35
PA may be required

Preventive & Comprehensive Dental Services:
You have a $1000 yearly allowance toward Preventive Dental, Comprehensive Dental, and/or Eyewear combined. You can see any licensed dentist or visit any eyewear retailer. You'll pay the costs yourself at first. Then, you can submit a request for reimbursement to Devoted. Cosmetic procedures, dental implants, and/or elective procedures are not covered.

Please see Summary of Benefits and Evidence of Coverage for more benefit information.

Eye Exams:
Copayment for Medicare Covered Benefits $15
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exam every year

Hearing Exams:
Copayment for Medicare Covered Benefits $15
Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $199 to $499

• Maximum 2 Hearing Aids every year

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal 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

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $5.00
• Standard mail order $5.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $10.00
• Standard mail order $10.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $15.00
• Standard mail order $12.50

• Summary of benefits
• Evidence of coverage
• Star ratings