Devoted CHOICE GIVEBACK Hawaii (PPO)

Inpatient Hospital See details

Inpatient Hospital benefits, including Acute and Psychiatric, are covered. For days 1-4, there is a $375 copay, and for days 5-90, there is no copay.

Outpatient Services See details

Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $475, and observation services have a $375 copay, while ambulatory surgical center services have no copay. Individual and group sessions for outpatient substance abuse services have a copay of $45.

Partial Hospitalization See details

Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan, with a $70 copay. Prior authorization is required.

Ambulance and Transportation Services See details

The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers ambulance services, including ground and air ambulance. Ground ambulance services have a copay of $0-$350, while air ambulance services have a 20% coinsurance. Transportation services to health-related locations are not covered.

Emergency Services See details

Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. Emergency Services have a $110 copay, while Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.

Primary Care See details

The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers Primary Care Physician Services, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $0-$35 copay, Physician Specialist Services with a $55 copay, Mental Health Specialty Services with a $45 copay for individual and group sessions, Other Health Care Professional services with a $0-$55 copay, Psychiatric Services with a $45 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a $0-$50 copay, Additional Telehealth Benefits with a $0-$55 copay, and Opioid Treatment Program Services with a $45 copay. Routine Chiropractic Care is not covered, and Podiatry Services are not covered.

Preventive Services See details

The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers preventive services, including annual physical exams, and additional preventive services like health education, weight management programs, alternative therapies, therapeutic massage, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy (MNT), post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, adult day health services, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.

Hearing Services See details

Hearing exams are covered with a $55 copay. Routine hearing exams are covered once per year, and fitting/evaluation for hearing aids are covered with no limit.

Prescription hearing aids are partially covered, with a copay between $599 and $899 for all types of prescription hearing aids, up to 2 per year; however, prescription hearing aids for the inner, outer, and over the ear are not covered. OTC hearing aids are not covered.

Vision Services See details

Devoted CHOICE GIVEBACK Hawaii (PPO) covers vision services, including eye exams with a $20 copay. Eyewear is covered with a combined maximum benefit of $250 every year for both in-network and out-of-network services.

Dental Services See details

The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers dental services with a $250 annual maximum, including oral exams, dental X-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Medicare dental services have a $55 copay, and orthodontic services are covered under diagnostic and preventive dental. Maxillofacial prosthetics, implant services, and orthodontics are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and 20% coinsurance. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.

Dialysis Services See details

Dialysis Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. You will pay 20% coinsurance.

Medical Equipment See details

Medical Equipment is covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. For Durable Medical Equipment, there is a 15% coinsurance and no copay. For Prosthetic Devices, there is between 0% to 15% coinsurance, and for Medical Supplies there is a 15% coinsurance.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services are covered, with varying costs depending on the specific service. Diagnostic Procedures/Tests have a copay between $0 and $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $300, and Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.

Home Health Services See details

Home Health Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.

Cardiac Rehabilitation Services See details

Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. Although the plan covers Cardiac Rehabilitation Services, none of the sub-services are covered.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan, but require prior authorization. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $170 copay. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.

Other Services See details

Other Services include acupuncture and other services, but over-the-counter items, meal benefits, and other services are not covered. Acupuncture is covered with no copay or coinsurance, and other services include $0 preventive services.