Summary of Benefits - Devoted Health Latitude South Florida (PPO) Plan PBP Number: H9884-001-000
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2022 | DEVOTED HEALTH PLANS Summary of Benefits Devoted Health Latitude South Florida (PPO) Plan PBP Number: H9884-001-000 Broward, Palm Beach Counties
Devoted Health Latitude South Florida (PPO)
Summary of Benefits
This Summary of Benefits tells you about our What’s the difference between copays and
Devoted Health Latitude South Florida (PPO) coinsurance?
plan. It includes information on plan costs and
some of the common services we cover. It's A copay is a flat fee. For example, a $5 copay
valid for the 2022 plan year, which starts on for a service means you pay $5. Coinsurance is
January 1, 2022 and ends December 31, 2022. a percentage of the cost. For example, 10%
coinsurance means you pay 10% of the cost of
Because this document is a summary, it the service.
doesn't list all of the coverage details for this
plan. If you need to know more, check the How can I learn about Original Medicare?
plan's Evidence of Coverage at
www.devoted.com. Or, call us at Check the latest Medicare & You handbook. If
1-800-385-0916 (TTY 711) and we can mail you you don’t have one, visit www.medicare.gov
one. and enter “Medicare & You handbook” in the
search tool. (Include the quotation marks for
Can I join this plan? best results.) Or ask Medicare to send you one
by calling 1-800-MEDICARE (1-800-633-4227)
Devoted Health Latitude South Florida (PPO) any day, any time. TTY users can dial
is a Preferred Provider Organization, or PPO 1-877-486-2048.
plan. To join Devoted Health Latitude South
Florida (PPO), you must be entitled to How can I get more help?
Medicare Part A and enrolled in Medicare Part
B. You also have to live in this plan’s service Call us at 1-800-385-0916 (TTY 711). We’re
area, which includes these counties: Broward, here 8am to 8pm, Monday to Friday (from
Palm Beach. We offer different plans for other October 1 to March 31, 8am to 8pm, 7 days a
counties. week). You can also visit us online at
www.devoted.com.
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.
Need Help? Call 1-800-385-0916 (TTY 711) 1Pre-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 1-800-385-0916 (TTY 711).
Understanding the Benefits Understanding Important Rules
Review the full list of benefits found in the You must continue to pay your
Evidence of Coverage (EOC), especially for Medicare Part B premium. This
those services for which you routinely see a premium is normally taken out of your
doctor. Visit www.devoted.com or call Social Security check each month.
1-800-385-0916 (TTY 711) to view a copy of Benefits, premiums, and/or
the EOC. copayments/co-insurance may change
As a member of this plan, you can see on January 1, 2023.
providers that are in Devoted Health's Our plan allows you to see providers
network, or you can choose to see doctors outside of our network (non-contracted
who are out of network. If you see an out of providers). However, while we will pay
network doctor, you may pay a higher cost for covered services provided by a non-
share. You can review the provider directory contracted provider, the provider must
(or ask your doctor) to see if the doctors agree to treat you. Except in an
you see now are in the Devoted Health emergency or urgent situations, non-
network. contracted providers may deny care. In
Review the pharmacy directory to make addition, you may pay a higher co-pay
sure the pharmacy you use for any for services received by non-contracted
prescription medicine is in the Devoted providers.
Health network. If the pharmacy is not
listed, you will likely have to select a new
pharmacy for your prescriptions.
2 Devoted Health Latitude South Florida (PPO)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) $150 for Tiers 3 - 5 only
Deductible If you receive Extra Help from Medicare, your
deductible may be as low as $0.
Maximum Out-of-Pocket In Network Out of Network
Responsibility
$3,500 $6,500
This is the most you will This is the most you will
pay for copays, pay for copays,
coinsurance, and other coinsurance, and other
costs for Medicare- costs for Medicare-
covered medical services, covered medical services,
supplies, and Part B- supplies, and Part B-
covered medication for covered medication you
the plan year. What you receive from in and out-
pay out-of-pocket for of-network providers
Part D prescription drugs combined for the plan
and certain supplemental year. What you pay out-
benefits (dental, hearing of-pocket for Part D
aids) do not apply to this prescription drugs and
amount. certain supplemental
benefits (dental, hearing
aids) do not apply to this
amount.
Need Help? Call 1-800-385-0916 (TTY 711) 3Covered Medical and Hospital Benefits
Inpatient Hospital In Network Out of Network
Coverage Days 1 - 5 Days 1 - 5
$250 copay per day $250 copay per day
Prior authorization may be
required. Days 6 + Days 6 +
$0 copay $0 copay
Outpatient Hospital In Network Out of Network
Coverage
Diagnostic Colonoscopies Diagnostic Colonoscopies
Prior authorization may be $0 copay at any in- 40% coinsurance at
required for procedures network location any out of network
performed in an Outpatient location
Hospital or Ambulatory Ambulatory Surgical
Surgical Center. Center (ASC) Ambulatory Surgical
$150 copay for surgery Center (ASC)
If you are held in Observation, at an ASC 40% coinsurance for
you will pay your copay for the surgery at an ASC
Observation Stay. Copays for Outpatient Hospital
any additional services $250 copay for surgery Outpatient Hospital
provided while in Observation at an outpatient 40% coinsurance for
will not apply. hospital surgery at an
outpatient hospital
Observation Stays
$250 copay per stay Observation Stays
40% coinsurance
Doctor Visits In Network Out of Network
You do not need a referral to Primary Care Provider Primary Care Provider
see a specialist. (PCP) (PCP)
$0 copay $35 copay
Specialist Specialist
$30 copay $60 copay
4 Devoted Health Latitude South Florida (PPO)Preventive Care Our plan covers many preventive services at no cost
when you see an in-network or out-of-network
provider, including:
• Abdominal aortic aneurysm screening
• Alcohol misuse counseling
• Annual wellness visit
• Bone mass measurement (bone density)
• Breast cancer screening (mammogram)
• Cardiovascular disease (behavioral therapy)
• Cardiovascular screenings
• Cervical and vaginal cancer screenings
• Colorectal cancer screenings (colonoscopy,
fecal occult blood test, flexible sigmoidoscopy,
Cologuard®)
• Depression screening
• Diabetes screening
• Diabetes self-management training
• Glaucoma tests
• Hepatitis C screening test
• HIV screening
• Lung cancer screening
• Medical nutrition therapy services
• Obesity screening and counseling
• Prostate cancer screenings (PSA)
• Routine physical exam
• Sexually transmitted infections screening and
counseling
• Tobacco use cessation counseling (counseling
for people with no sign of tobacco-related
disease)
• Vaccines covered under the medical benefit,
including flu shots, hepatitis B shots,
pneumococcal shots
• “Welcome to Medicare” preventive visit (one
time)
Any additional preventive services approved by
Medicare during the contract year will be covered.
Need Help? Call 1-800-385-0916 (TTY 711) 5Emergency Care $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.
Worldwide Emergency and Emergency Care
Urgent Care $90 copay
This plan covers emergency Urgently Needed Services
services worldwide. If you have $40 copay
an emergency outside of the U.S. Ground Ambulance
and its territories, you generally
$250 copay
have to pay the costs yourself at
per one-way trip
first. Then, you can submit a
claim to us so we can pay you Air Ambulance
back. 20% coinsurance
per one-way trip
Urgently Needed Services In Network Out of Network
Urgently needed services Urgently needed services
from your PCP from your PCP
$0 copay $35 copay
Urgently needed services Urgently needed services
from an urgent care center from an urgent care center
or retail walk-in center or retail walk-in center
$40 copay $40 copay
Urgently needed services Urgently needed services
are provided to treat a are provided to treat a
non-emergency, non-emergency,
unforeseen medical unforeseen medical
illness, injury, or illness, injury, or
condition that requires condition that requires
immediate medical care. immediate medical care.
6 Devoted Health Latitude South Florida (PPO)Outpatient Care and Services
Diagnostic Services, Labs In Network Out of Network
and Imaging
Lab Services Lab Services
Prior authorization may be $0 copay in an office or 40% coinsurance
required. freestanding location
Outpatient X-rays &
$25 copay at an Ultrasounds
If your provider bills us as part
outpatient hospital 40% coinsurance
of a hospital system, you may
be responsible for the setting
Diagnostic Radiology (such
outpatient hospital setting cost Outpatient X-rays & as CT, MRI, etc.)
share for the services outlined Ultrasounds 40% coinsurance
in this section. $0 copay in an office or
freestanding location Diagnostic Tests and
Procedures (such as a
$25 copay at an
stress test, etc.)
outpatient hospital
40% coinsurance
setting
Radiation Therapy
Diagnostic Radiology (such
40% coinsurance
as CT, MRI, etc.)
$0 copay in an office or
freestanding location
$150 copay at an
outpatient hospital
setting
Diagnostic Tests and
Procedures (such as a
stress test, etc.)
$0 copay in an office or
freestanding location
$25 copay at an
outpatient hospital
setting
Radiation Therapy
20% coinsurance
Need Help? Call 1-800-385-0916 (TTY 711) 7Hearing Services
Hearing Care In Network Out of Network
Routine Hearing Exams Routine Hearing Exams
$0 copay — 1 visit per $60 copay — 1 visit per
year year
Hearing Aid Fitting and Hearing Aid Fitting and
Evaluation Evaluation
$0 copay $0 copay
Medicare-covered Hearing Medicare-covered Hearing
Care Care
$30 copay $60 copay
Hearing Aids $399 copay per aid for Advanced Aids*
You must see a TruHearing® $699 copay per aid for Premium Aids*
provider to use this benefit.
Benefit includes coverage of up Hearing aid purchase includes:
to two TruHearing® Advanced or
Premium hearing aids, which • First year of follow-up provider visits
come in various styles and • 60-day trial period
colors. • 3-year extended warranty
• 80 batteries per aid for non-rechargeable
models
• $50 additional cost per aid for optional hearing
aid rechargeability
*Hearing aid copayments are not subject to the out-
of-pocket maximum.
8 Devoted Health Latitude South Florida (PPO)Vision Services
Routine Vision In Network Out of Network
Routine Eye Exam Routine Eye Exam
$0 copay — 1 visit per $60 copay — 1 visit per
year year
Diabetic Eye Exam Diabetic Eye Exam
$0 copay - 1 visit per $0 copay - 1 visit per
year year
Glaucoma Screening Glaucoma Screening
$0 copay $0 copay
Medicare-covered Vision In Network Out of Network
Care
$30 copay $60 copay
Dental and Eyewear Allowance
You have a $1,250 allowance towards Preventive Dental, Comprehensive Dental, and/or Eyewear
combined. You can see any licensed dentist or visit any eyewear provider. You do not need to use
a network provider for this benefit. You'll pay the costs yourself at first. Then, you can submit a
reimbursement request to us so we can pay you back. We will reimburse you up to your annual
limit.
Cosmetic or elective procedures are not eligible for reimbursement. See your Evidence of
Coverage for more information.
Need Help? Call 1-800-385-0916 (TTY 711) 9Additional Outpatient Care and Services
Mental Health Services In Network Out of Network
Prior authorization may be Inpatient mental health Inpatient mental health
required. care care
Days 1 - 5 Days 1 - 5
Mental health services are $250 copay per day $250 copay per day
coordinated by Magellan, our
behavioral health provider. Days 6 - 90 Days 6 - 90
$0 copay $0 copay
Outpatient mental health Outpatient mental health
care (individual and group) care (individual and group)
$30 copay $60 copay
Skilled Nursing Facility In Network Out of Network
(SNF) Days 1 - 20
50% coinsurance
$0 copay
Prior authorization may be
required. No prior hospital stay Days 21 - 40
required. $184 copay per day
Days 41 - 100
$0 copay
Physical Therapy In Network Out of Network
$30 copay $60 copay
Ambulance Services In Network Out of Network
This plan covers you for Ground Ambulance Ground Ambulance
ambulance transportation to $250 copay $250 copay
the nearest emergency room per one-way trip per one-way trip
worldwide.
Air Ambulance Air Ambulance
20% coinsurance 20% coinsurance
per one-way trip per one-way trip
10 Devoted Health Latitude South Florida (PPO)Prescription Drug Benefits
Medicare Part B Drugs In Network Out of Network
Generally, Part B drugs are Allergy Serum Allergy Serum
usually not self-administered. $0 copay 50% coinsurance
These drugs can be given in a
doctor’s office as part of a Generic Medications Used Generic Medications Used
medical service. In a hospital in a Nebulizer in a Nebulizer
outpatient department, $0 copay 50% coinsurance
coverage generally is limited to
Chemotherapy Drugs Chemotherapy Drugs
drugs that are given by infusion
or injection. You only pay the 20% coinsurance 50% coinsurance
cost-share for the amount of Other Part B Drugs Other Part B Drugs
the drug used. This means that 20% coinsurance 50% coinsurance
if part of the drug is not used,
you will not be charged for the
unused portion.
Prior authorization may be
required.
Prescription Drugs Pharmacy (Part D) Deductible
$150 for Tiers 3 - 5 only
If you receive extra help from Medicare, your
deductible may be as low as $0.
There is no deductible for Devoted Health Latitude
South Florida (PPO) for Select Insulins. During the
Deductible Stage, your out-of-pocket costs for these
Select Insulins will be $35 for a 30-day supply.
Initial Coverage Stage
You pay copays or coinsurance until your total yearly
drug costs reach $4,430. Total yearly drug costs are
the total drug cost paid by both you and Devoted
Health.
Need Help? Call 1-800-385-0916 (TTY 711) 1130-Day Supply Network Tier 1: Preferred Generic
Retail Pharmacy $0 per prescription
Cost sharing may change when Tier 2: Generic
you enter a new phase of the Part $0 per prescription
D benefit. Tier 3: Preferred Brand
$47 per prescription
Select Insulin: $35 per prescription
See the Additional Part D Benefit Information
section.
Tier 4: Non-Preferred Drugs
$100 per prescription
Tier 5: Specialty
30% of the total cost
100-Day Supply Network Tier 1: Preferred Generic
Mail Order $0 per prescription
Cost sharing may change when Tier 2: Generic
you enter a new phase of the Part $0 per prescription
D benefit. Tier 3: Preferred Brand
$117.50 per prescription
Select Insulin: $105 per prescription
See the Additional Part D Benefit Information
section.
Tier 4: Non-Preferred Drugs
$300 per prescription
Tier 5: Specialty
Not available through mail
If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy. While
you reside in the long term care facility you are able to receive up to a 31 day supply.
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
$4,430. Please note that not everyone will enter the Coverage Gap.
12 Devoted Health Latitude South Florida (PPO)This plan provides partial tier gap coverage for tier 1 and tier 2 drugs. This means that for
some of the drugs covered in tier 1 and tier 2, you will continue to pay a copay. For the 2022 plan
year, while in the coverage gap, you will pay $0 for certain drugs in tiers 1-2, and 25% of the
total cost for all other drugs until you reach $7,050 total out-of-pocket. Drugs that have partial
gap coverage are indicated in the Plan Formulary (Drug list).Devoted Health Latitude South
Florida (PPO) offers additional gap coverage for Select Insulins. During the Coverage Gap stage,
your out-of-pocket costs for Select Insulins will be $35 for a 30-day supply.
Catastrophic Coverage
Yearly Out-of-pocket Drug After you reach $7,050 yearly out-of-pocket drug costs,
Costs you pay the greater of:
5% of the cost
— or —
Generic Drugs or Drugs that are Treated as Generic
$3.95
Covered Brand Drugs
$9.85
Devoted Health pays the rest of the cost.
Additional Part D Benefit Information
Insulin Coverage With this plan, you pay a $35 copay for a 30-day
supply of select insulin products covered on
As a member of this plan, you our formulary.
have extra coverage and savings
for select insulin drugs. 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 drug costs.
Erectile Dysfunction Drugs Sildenafil (generic Viagra) and Tadalafil (generic
(ED) Cialis) are both covered as Tier 2 medications.
You are covered up to 6 pills per month (a
maximum of 72 pills per year), for either
medication or combination, but not to exceed 6
pills.
Need Help? Call 1-800-385-0916 (TTY 711) 13Additional Prescription Drug If you receive Extra Help from Medicare, your costs for
Information 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.
Note: some covered drugs may be subject to quantity
limitations, or require step therapy or prior
authorization.
Additional Benefits
Dialysis In Network Out of Network
20% coinsurance 20% coinsurance
Foot Care (Podiatry In Network Out of Network
Services)
Medicare-covered Foot Medicare-covered Foot
Care Care
$30 copay $60 copay
Routine Foot Care Routine Foot Care
$30 copay — 6 visits $60 copay — 6 visits
per year per year
Routine foot care Routine foot care
includes hygienic care includes hygienic care
such as nail trimming and such as nail trimming and
callus removal. callus removal.
6 visits per year combined between in and out of
network
14 Devoted Health Latitude South Florida (PPO)Home Health Care In Network Out of Network
Prior authorization may be $0 copay 40% coinsurance
required.
Home Health Care is limited to
Medicare-covered services.
Need Help? Call 1-800-385-0916 (TTY 711) 15Durable Medical In Network Out of Network
Equipment (DME)
Basic Medicare-covered Basic Medicare-covered
Prior authorization may be DME products DME products
required. 20% coinsurance 50% coinsurance
Including, but not limited Including, but not limited
to: to:
• Oxygen • Oxygen
• CPAP machines and • CPAP machines and
supplies supplies
• Nebulizer • Nebulizer
equipment equipment
• Non-motorized • Non-motorized
wheelchair wheelchair
Advanced Medicare- Advanced Medicare-
covered DME products covered DME products
(listed below) (listed below)
20% coinsurance 50% coinsurance
• Medicare-covered • Medicare-covered
ventilator ventilator
• Bone growth • Bone growth
stimulator stimulator
• Portable oxygen • Portable oxygen
concentrator concentrator
• Bariatric equipment • Bariatric equipment
• Specialty beds • Specialty beds
• Custom or specialty • Custom or specialty
wheelchairs and wheelchairs and
scooters scooters
• Seat lifts • Seat lifts
• Specialty brand • Specialty brand
items items
• High-frequency • High-frequency
chest compression chest compression
vests vests
• Pain infusion pump • Pain infusion pump
16 Devoted Health Latitude South Florida (PPO)• Continuous Glucose • Continuous Glucose
Monitor (other than Monitor (other than
Freestyle Libre - see Freestyle Libre - see
"Diabetic "Diabetic
Monitoring Monitoring
Supplies" section Supplies" section
for details) for details)
Equipment is covered
only from certain brands
and manufacturers.
Please contact us for
details.
Prosthetic Devices and In Network Out of Network
Medical Supplies
Prosthetic devices and Prosthetic devices and
related supplies related supplies
Prior authorization may be 20% coinsurance 50% coinsurance
required.
Medical Supplies Medical Supplies
$0 copay 50% coinsurance
Supplemental compression Supplemental compression
stockings stockings
$0 copay 50% coinsurance
Supplemental mastectomy Supplemental mastectomy
sleeves sleeves
$0 copay 50% coinsurance
Up to two pairs every 6 Up to two pairs every 6
months of compression months of compression
stockings/surgical stockings/surgical
stockings or mastectomy stockings or mastectomy
sleeves sleeve
Need Help? Call 1-800-385-0916 (TTY 711) 17Diabetic Monitoring In Network Out of Network
Supplies
Supplies to monitor your Supplies to monitor your
Prior authorization may be blood glucose blood glucose
required. $0 copay 40% coinsurance
"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.
Diabetic Shoes & In Network Out of Network
Therapeutic Inserts
$0 copay 40% coinsurance
18 Devoted Health Latitude South Florida (PPO)Rehabilitation Services In Network Out of Network
Cardiac rehabilitation Cardiac rehabilitation
services services
$20 copay 40% coinsurance
Pulmonary rehabilitation Pulmonary rehabilitation
services services
$20 copay 40% coinsurance
Physical Therapy Physical Therapy
$30 copay $60 copay
Occupational Therapy Occupational Therapy
$30 copay $60 copay
Speech Therapy Speech Therapy
$30 copay $60 copay
Substance Use Services In Network Out of Network
$30 copay $60 copay
Telehealth In Network Out of Network
This benefit may not be offered Virtual PCP Visits Virtual PCP Visits
by all providers. Check directly $0 copay $35 copay
with your provider about the
availability of telehealth Virtual PT/OT/SP Visits Virtual PT/OT/SP Visits
services. $30 copay $60 copay
Virtual Specialist Visits Virtual Specialist Visits
$30 copay $60 copay
Your costs may be less Your costs may be less
depending on the depending on the
provider you see. provider you see.
Need Help? Call 1-800-385-0916 (TTY 711) 19More Benefits and Perks With Your Plan
Over-the-Counter Items
(OTC) $90 per quarter
You must use our designated You can use this benefit more than once, up to
vendor for this benefit. the limit per quarter, but this amount does not
roll over.
Eligible items are listed in the OTC catalog. Items not
listed in the OTC catalog are not covered under the
OTC benefit. To purchase eligible OTC items, you can
order online, over the phone, or visit participating CVS
stores.
20 Devoted Health Latitude South Florida (PPO)Fitness
SilverSneakers: Devoted Health covers the full
cost of this benefit. SilverSneakers fitness
program offers access to thousands of fitness
locations nationwide. SilverSneakers also
provides virtual resources through
SilverSneakers LIVE™, SilverSneakers On-
Demand™ and a mobile app, SilverSneakers
GO™.
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:
1. Purchase of an Apple Watch® or other
wearable device that tracks number of steps
and heart rate.
2. Fitness equipment to be used in the home.
Examples include free weights, treadmill or
stationary bike, rowing machines, resistance
bands, etc.
3. 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.
4. Program fees for weight loss programs such
as Jenny Craig, Weight Watchers, or
hospital-based weight loss programs.
5. Memory fitness activities and programs that
improve your brain’s speed and ability,
strengthen memory, and enable learning.
6. Mindfulness apps, such as Calm or
Headspace, to support you health and well-
being.
Need Help? Call 1-800-385-0916 (TTY 711) 21Acupuncture In Network Out of Network
Medicare coverage is limited to Medicare-covered Medicare-covered
treatment of chronic lower acupuncture acupuncture
back pain. Certain restrictions $0 copay $60 copay
and limitations apply.
Meals After an Inpatient or Skilled Nursing Facility Stay
$0 copay
You must use our designated
vendor for this benefit. 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.
New Chronic Condition or Medical Condition requiring a
Home Stay
$0 copay
If part of your care plan for a chronic condition means
changing how you eat, or you are diagnosed with a
condition that requires you stay at home, you can
have meals delivered to your home to support your
condition.
You can get 2 meals a day for 14 days. You can use
this service once per calendar year, per diagnosis.
Chiropractic Care In Network Out of Network
Medicare-covered Medicare-covered
chiropractic services chiropractic services
$20 copay $20 copay
Routine chiropractic care Routine chiropractic care
$20 copay — 6 visits $20 copay — 6 visits
per year per year
6 visits per year between in and out of network
22 Devoted Health Latitude South Florida (PPO)Bathroom Safety In Network Out of Network
Equipment
Standard Raised Toilet Standard Raised Toilet
Seat: Seat:
$0 copay 50% coinsurance
Standard Tub Seat: Standard Tub Seat:
$0 copay 50% coinsurance
Personal Emergency $0 copay
Response System (PERS)
There is no cost to you to access this benefit. This
A Personal Emergency Response includes:
System (PERS) is a medical alert
monitoring system that provides • Cost of the device
24/7 access to help at the push • Monthly monitoring fees
of a button. • Fall detection (available on certain styles)
We offer multiple styles,
including in-home and multiple
mobile-enabled wearable
devices.
You must use our designated
vendor for this benefit.
Wigs for Hair Loss Related to Devoted Health will reimburse you up to $200
Chemotherapy each plan year for the purchase of wigs for hair
loss related to chemotherapy.
You may use any vendor for this
benefit.
Need Help? Call 1-800-385-0916 (TTY 711) 23Devoted Dollars Breast Cancer or Colorectal Cancer Screening:
Earn a $20 reward after a breast cancer
With our rewards program, you screening (if you’re due for one) OR a colorectal
can earn Devoted Health Plans
cancer screening (if you’re due for one)
Visa® prepaid cards for taking
care of yourself.
Diabetes Screening: Earn a $20 reward after
When we receive a claim from receiving all of the following services (if you have
your provider for any of the diabetes):
eligible services, we will issue
you a reward. • Get a blood test to check your HbA1c
(average blood sugar)
• Get a urine test to check your kidney
function
• Get an eye exam for diabetes
Flu Shot: Earn a $10 reward after receiving the
flu shot
PCP Visit: Earn a $20 reward after seeing your
PCP within 90 days of your plan start date
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 Devoted Health Latitude South Florida (PPO)This information is not a complete description of benefits. Call 1-800-385-0916 (TTY 711) for more
information. Devoted Health is an HMO and PPO plan with a Medicare contract. Our D-SNPs also
have contracts with State Medicaid programs. Enrollment in our plans depends on contract
renewal.
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support please visit an Apple authorized retailer.
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Need Help? Call 1-800-385-0916 (TTY 711) 2728 Devoted Health Latitude South Florida (PPO)
If you're a Devoted Health Questions? Call us. member, call: 1-800-385-0916 1-800-338-6833 TTY 711 TTY 711
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