Plan Benefits Summary of Benefits 2019 Devoted Health Prime Greater Tampa Bay (HMO) Plan Devoted Health Prime Greater Tampa Bay (HMO) Plan 11
12 Need Help? Call 1-800-338-6833 (TTY 711)
Devoted Health Prime Greater Tampa Bay (HMO) Plan Summary of Benefits The Summary of Benefits tells you more about our Devoted Health Prime Greater Tampa Bay (HMO) plan, like some of your costs and some of the services we pay for. Devoted Health offers Medicare Advantage HMO plans with a Medicare contract. Enrollment in the Plan depends on contract renewal. It might seem long, but it doesn t get into every last detail on what s covered and what s not. If you need to dig into the nitty gritty, you can check out the plan s Evidence of Coverage. Just give us a call at 1-800-338-6833 (TTY 711) and ask for one. You can also find it online at www.devoted. com/plan-documents. How can I find out what prescription drugs Devoted covers? This guide has a list of the most common drugs we cover, so you can check that for starters. To get the full list, call us and we ll mail you one. Or, you can go to www. devoted.com/search-drugs you ll see the link you need right on the home page. How can I find out if my doctors and pharmacies are in Devoted s plan? Give us a call. We can mail you a directory or look something up for you. You can also go to www.devoted.com/search-providers you ll see the links you need on our homepage. Plan Benefits This Summary of Benefits is for plans that run from January 1, 2019 to December 31, 2019. How can I learn more about Original Medicare? If you re wondering about the coverage and costs of Original Medicare, check the latest Medicare & You handbook. If you don t have one, you can: Visit medicare.gov and search for Medicare & You Handbook. Ask Medicare for a copy by calling 1-800-MEDICARE (1-800-633-4227) any day, any time. TTY users can dial 1-877-486-2048. Devoted Health Prime Greater Tampa Bay (HMO) Plan 13
Pre-Enrollment Checklist Before 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 1-800-338-6833 (TTY 711). Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit www. devoted.com/plan-documents or call 1-800-338-6833 (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 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 medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. Benefits, premiums and/or copayments/ coinsurance may change every year. 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). 14 Need Help? Call 1-800-338-6833 (TTY 711)
Monthly Premium, Deductible and Limits Monthly Premium $30.30 If you receive Extra Help from Medicare, depending on the level of Extra Help you receive, the plan premium may be reduced to $0. You must continue to pay your Medicare Part B premium. The Part B premium may be covered through your State Medicaid Program. Plan Benefits Medical Deductible Pharmacy (Part D) Deductible Maximum Out-ofpocket Responsibility None $415 The Deductible does NOT apply to Tier 1 drugs. $3,400 in network The most you pay for copays, coinsurance and other costs for medical services for the plan year. Covered Medical and Hospital Benefits Inpatient Hospital Coverage Outpatient Surgery Prior authorization may be required. At Outpatient Hospital or Ambulatory Surgical Center. Prior authorization may be required. Doctor Visits Primary Care Provider Specialist A referral from your PCP is required to see a specialist. Devoted Health Prime Greater Tampa Bay (HMO) Plan 15
Preventive Care Our plan covers many preventive services at no cost when you see an in-network provider, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement (bone density) Breast cancer screening (mammogram) Cardiovascular disease (behavorial therapy) Cardiovascular screenings Cervical and vaginal cancer screenings Colorectal cancer screenings (colonscopy, fecal ocult blood test, flexible sigmoidoscopy, Cologuard) Depression screening Diabetes screening HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including flu shots, hepatitis B shots, pneumococcal shots Welcome to Medicare preventive visit (one time) Annual wellness visit Lung cancer screening Routine physical exam Diabetes self-management training Glacoma tests Hepatitis C screening tests Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Room $90 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 Needed Services Urgent Care Centers Urgently needed services are provided to treat a nonemergency, unforeseen medical illness, injury or condition that requires immediate medical care. 16 Need Help? Call 1-800-338-6833 (TTY 711)
Outpatient Care and Services Diagnostic Services, Labs and Imaging Prior authorization may be required. Advanced Imaging Services Lab Services Diagnostic Tests and Procedures Outpatient X-rays Radiation Therapy Plan Benefits Hearing Hearing Care Medicare-covered Hearing Care Routine Hearing Exams 1 per calendar year Hearing Aid Fitting and Evaluation 1 per calendar year Hearing Aids $750 max per ear per year Devoted Health Prime Greater Tampa Bay (HMO) Plan 17
Dental Medicare-covered Dental Services Prior authorization may be required. Preventive Dental Services Periodic Oral Exams up to 2 per calendar year Comprehensive Oral Evaluation up to 1 every 3 calendar years Prophylaxis (Cleaning) up to 2 per calendar year Bitewing X-rays up to 1 per calendar year Full Mouth (Panoramic) X-rays up to 1 per calendar year Comprehensive Dental Services Prior authorization may be required. Amalgam (Silver) or Resin-based Composite (White) Fillings up to 4 fillings per calendar year Dentures up to 1 upper and lower complete or partial denture every 5 calendar years Relining Complete Dentures up to 1 per calendar year Extractions up to 3 extractions per calendar year Scaling and Root Planing up to 1 procedure per quadrant every 2 calendar years Full Mouth Debridement up to 1 every 2 calendar years 18 Need Help? Call 1-800-338-6833 (TTY 711)
Vision Medicare-Covered Vision Care Routine Vision Prior authorization and referral may be required. Routine Eye Exam, Including Refraction 1 exam per calendar year Plan Benefits Eyewear Eyeglasses or Contact Lenses Up to $250 maximum benefit coverage per year Additional Outpatient Care and Services Mental Health and Substance Use Services Inpatient Prior authorization may be required. Outpatient Mental Health Care Visit Outpatient Substance Use Visit Skilled Nursing Facility (SNF) Ambulance Transportation Prior authorization may be required. No prior hospital stay required. $150 copay Prior authorization may be required for non-emergency care. up to 50 one-way trips per year Devoted Health Prime Greater Tampa Bay (HMO) Plan 19
Prescription Drug Benefits Medicare Part B Drugs Cost sharing may vary based on where the service is provided. Prior authorization may be required. Chemotherapy Drugs 0 to 20% of the total costs Other Part B Drugs 0 to 20% of the total costs Prescription Drugs Pharmacy (Part D) Deductible $415 The Deductible does NOT apply to Tier 1 drugs. Initial Coverage Stage You pay copays or coinsurance until your total yearly drug costs reach $3,820. 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 depending on the pharmacy you choose and when you enter a new phase of the Part D benefit. Tier 1: Preferred Generic Drugs Tier 2: Generic Drugs $2 copay Tier 3: Preferred Brand Drugs 25% of the cost Tier 4: Non-Preferred Drugs 25% of the cost Tier 5: Specialty Drugs 25% of the cost 20 Need Help? Call 1-800-338-6833 (TTY 711)
90-Day Supply Network Mail Order Cost sharing may change depending on the pharmacy you choose and when you enter a new phase of the Part D benefit. Tier 1: Preferred Generic Drugs Tier 2: Generic Drugs Tier 3: Preferred Brand Drugs 25% of the cost Tier 4: Non-Preferred Drugs 25% of the cost Tier 5: Specialty Drugs Not available through mail order. Plan Benefits Erectile Dysfunction Drugs (ED) Covered at Tier 2 copay amount If you reside in a long term care facility, you pay the same as at a standard retail pharmacy 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. If you reside in a long term care facility, you pay the same as at a standard retail pharmacy. Devoted Health Prime Greater Tampa Bay (HMO) Plan 21
Coverage Gap or Donut Hole Most Medicare drug plans have a Coverage Gap or donut hole. This means that there is a temporary change in what you will pay for your drugs. The Coverage Gap begins after the total yearly drug costs (including what Devoted Health has paid and what you have paid) reaches $3,820. Please note that not everyone will enter the Coverage Gap. For the 2019 plan year, while in the coverage gap, you will pay a 25% copay for brand drugs and 37% copay for generic until you reach $5,100 total out-of-pocket. Catastrophic Coverage Yearly Out-of-pocket Drug Costs After you reach $5,100 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 $3.40 Covered Brand Drugs $8.50 Devoted Health pays the rest of the cost. 22 Need Help? Call 1-800-338-6833 (TTY 711)
Additional Benefits Dialysis Foot Care (Podiatry Services) Prior authorization may be required. Medicare-covered Foot Exams and Treatment Routine Foot Care up to 6 visits per year Plan Benefits Home Health Care Prior authorization may be required Durable Medical Equipment (DME) 0% of the cost Prior authorization may be required. Equipment is covered only from certain brands and manufacturers. Please contact us for details. Diabetic Monitoring Supplies Prior authorization may be required. Supplies are covered only from certain brands and manufacturers. Please contact us for details. Rehabilitation Services Cardiac Rehabilitation Pulmonary Rehabilitation Physical, Occupational and Speech Therapy Prior authorization may be required. Devoted Health Prime Greater Tampa Bay (HMO) Plan 23
More Benefits With Your Plan Over-the-counter Items (OTC) Fitness Program Acupuncture $60 per month up to $720 per year Eligible items are listed in the OTC catalog. Items not listed in the OTC catalog are not covered under the OTC benefit. SilverSneakers up to 12 visits per year Meals After an Inpatient or Skilled Nursing Facility Stay $0 up to 16 meals (2 meals per day for up to 8 days) Post-discharge benefit may be used up to 4 times per calendar year. Meals to Get You Started if a Chronic Condition Diagnosis Means Changing How You Eat $0 up to 28 meals (2 meals per day for up to 14 days) Chronic condition benefit may be used up to once per calendar year. You need a referral to receive covered services from providers. Certain procedures, services and drugs may need advance approval from Devoted Health. This is called prior authorization or pre-authorization. Please contact your PCP or refer to the Evidence of Coverage for services that require a prior authorization from Devoted Health. 24 Need Help? Call 1-800-338-6833 (TTY 711)
Plan Benefits This information is not a complete description of benefits. Call 1-800-338-6833 (TTY 711) for more information. Devoted Health is a HMO plan with a Medicare contract. Enrollment in Devoted Health depends on contract renewal. H1290_19P091_M Devoted Health Prime Greater Tampa Bay (HMO) Plan 25